THE USE OF PERIOPERATIVE EPIDURAL ANALGESIA AND THE OUTCOMES OF SURGICAL TREATMENT FOLLOWING PANCREATODUODENECTOMY: A CLINICAL STUDY

Authors

DOI:

https://doi.org/10.11603/2414-4533.2024.2.14840

Keywords:

pancreaticoduodenectomy, epidural analgesia, general anesthesia, postoperative pancreatic fistula, hemodynamic stability, complications

Abstract

The aim of the work: to evaluate the clinical significance of the use of perioperative epidural analgesia on short-term postoperative complications after pancreaticoduodenectomy (PD), taking into account other significant covariates.

Materials and Methods. A retrospective review was conducted using a prospectively collected database of consecutive patients who underwent PD from January 2022 to November 2023. The patient group consisted of 234 patients (150 men and 84 women) with an average age of 68 years. The approaches to analgesia provision were different: 20 patients (8 %) were limited to general analgesia alone, while the majority of 215 patients (92 %) received a combined method that included both epidural and general analgesia. Preoperative biliary drainage was performed in 122 patients (52 %). Postoperative pancreatic fistula (POPF) developed in 44 patients (18,8 %). Standard descriptive statistics were used to compare preoperative parameters between the epidural and general analgesia groups. Additionally, Pearson correlation analysis was used to examine the relationship between the use of epidural analgesia and key postoperative parameters.

Results and Discussion. The use of combined epidural and general anesthesia was associated with improvements in several postoperative outcomes compared with general anesthesia alone. In particular, the use of epidural analgesia was associated with a significantly lower incidence of clinically significant POPF, with the majority of patients (88,78 %) showing no signs of this complication. In particular, the use of epidural analgesia was associated with a significantly shorter time to recovery of gastrointestinal function in the epidural analgesia group (3,35 days) compared with the general anesthesia group (5,5 days, p < 0.00001). Mean arterial pressure was significantly higher in the epidural group (71 mm Hg) compared to the general anesthesia group (66 mm Hg). Pearson’s correlation analysis revealed a significant inverse correlation between epidural analgesia and the risk of developing POPF (-0.635), as well as a positive effect of epidural analgesia on the rate of recovery of bowel function and hemodynamic stability.

The results of the study show that the wider use of a combination of epidural analgesia and general anesthesia may become the standard of care for patients undergoing complex abdominal surgery. The benefits include accelerated recovery of gastrointestinal function and reduced incidence and severity of POPF. However, potential risks must be considered and a careful choice of anesthetic strategy must be made based on individual patient characteristics. A multidisciplinary approach to the planning and implementation of PD is a key to achieving optimal results.

References

Giuliani T, Perri G, Kang R, Marchegiani G. Current Perioperative Care in Pancreatoduodenectomy: A Step-by-Step Surgical Roadmap from First Visit to Discharge. Cancers (Basel) 2023 Apr 26;15(9):2499. doi: 10.3390/cancers15092499. PMID: 37173964; PMCID: PMC10177600.

Kokkinakis S, Kritsotakis EI, Maliotis N, Karageorgiou I, Chrysos E, Lasithiotakis K. Complications of modern pancreaticoduodenectomy: A systematic review and meta-analysis. Hepatobiliary Pancreat Dis Int 2022 Dec;21(6):527-537. doi: 10.1016/j.hbpd.2022.04.006. Epub 2022 Apr 25. PMID: 35513962.

Busquets J, Martín S, Secanella L, Sorribas M, Cornellà N, Altet J, Peláez N, Bajen M, Carnaval T, Videla S, Fabregat J. Delayed gastric emptying after classical Whipple or pylorus-preserving pancreatoduodenectomy: a randomized clinical trial (QUANUPAD). Langenbecks Arch Surg 2022 Sep;407(6):2247-2258. doi: 10.1007/s00423-022-02583-9. Epub 2022 Jul 4. PMID: 35786739; PMCID: PMC9468034.

Wittel UA, Makowiec F, Sick O, Seifert GJ, Keck T, Adam U, Hopt UT. Retrospective analyses of trends in pancreatic surgery: indications, operative techniques, and postoperative outcome of 1,120 pancreatic resections. World J Surg Oncol 2015 Mar 12;13:102. doi: 10.1186/s12957-015-0525-6. PMID: 25880929; PMCID: PMC4364492.

Keck T, Wellner UF, Bahra M, Klein F, Sick O, Niedergethmann M, Wilhelm TJ, Farkas SA, Börner T, Bruns C, Kleespies A, Kleeff J, Mihaljevic AL, Uhl W, Chromik A, Fendrich V, Heeger K, Padberg W, Hecker A, Neumann UP, Junge K, Kalff JC, Glowka TR, Werner J, Knebel P, Piso P, Mayr M, Izbicki J, Vashist Y, Bronsert P, Bruckner T, Limprecht R, Diener MK, Rossion I, Wegener I, Hopt UT. Pancreatogastrostomy Versus Pancreatojejunostomy for RECOnstruction After PANCreatoduodenectomy (RECOPANC, DRKS 00000767): Perioperative and Long-term Results of a Multicenter Randomized Controlled Trial. Ann Surg 2016 Mar;263(3):440-9. doi: 10.1097/SLA.0000000000001240. PMID: 26135690; PMCID: PMC4741417.

Deng S, Luo J, Ouyang Y, Xie J, He Z, Huang B, Bai F, Xiao K, Yin B, Wang J, Xu B, Zuo C. Application analysis of omental flap isolation and modified pancreaticojejunostomy in pancreaticoduodenectomy (175 cases). BMC Surg 2022 Apr 2;22(1):127. doi: 10.1186/s12893-022-01552-9. PMID: 35366868; PMCID: PMC8976960.

Jabłońska B, Mrowiec S. Pancreatectomy and Pancreatic Surgery. Life (Basel) 2023 Jun 16;13(6):1400. doi: 10.3390/life13061400. PMID: 37374182; PMCID: PMC10326818.

Kumar V, Prasad J. Postoperative morbidity following Whipple’s procedure for periampullary carcinoma: a retrospective study spanning 5 years. International Journal of Research in Medical Sciences 2019; 7(11): 4314–4319. doi: 10.18203/2320-6012.ijrms20195008.

Alemanno G, Bergamini C, Martellucci J, Somigli R, Prosperi P, Bruscino A, et al. Surgical outcome of pancreaticoduodenectomy: high volume center or multidisciplinary management? Minerva Chir 2016;71(1):8–14.

Guay J, Kopp, S. Epidural analgesia for adults undergoing cardiac surgery with or without cardiopulmonary bypass. The Cochrane database of systematic reviews 2019; 3:CD006715. https://doi.org/10.1002/14651858.CD006715.pub3.

Axelrod TM, Mendez BM, Abood GJ, Sinacore JM, Aranha GV, Shoup M. Peri-operative epidural may not be the preferred form of analgesia in select patients undergoing pancreaticoduodenectomy. J Surg Oncol 2015 Mar;111(3):306-10. doi: 10.1002/jso.23815. Epub 2014 Oct 31. PMID: 25363211.

Balkan B, Demirayak G, Çetingök H, Comba C, Yener Y, Hergünsel G, & Özdemir İ. Comparison of epidural and intravenous route for acute and chronic postoperative pain control in patients with gynecological malignancy. The journal of the Turkish Society of Algology 2020; 32(2): 91-98. doi: 10.14744/agri.2019.26986.

Bassi C, Marchegiani G, Dervenis C, Sarr M, Abu Hilal M, Adham M, et al. The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after. Surgery 2016; 161:584–591. doi: 10.1016/j.surg.2016.11.014.

Kooij FO, Schlack WS, Preckel B, Hollmann MW. Does regional analgesia for major surgery improve outcome? Focus on epidural analgesia. Anesth Analg 2014; 119(3):740–4.

Rawal N. Epidural technique for postoperative pain: gold standard no more? Reg Anesth Pain Med 2012; 37(3):310–7.

Andrianello S, Marchegiani G, Bannone E, Masini G, Malleo G, Montemezzi GL, et al. Clinical implications of intraoperative fluid therapy in pancreatic surgery. J Gastrointest Surg 2018; 22(12):2072–9.

Myles PS, Bellomo R, Corcoran T, Forbes A, Peyton P, Story D, et al. Restrictive versus liberal fluid therapy for major abdominal surgery. N Engl J Med 2018; 378(24):2263–74.

III K, Zimmerman N, Maheshwari K, Cooper G, Cummings L. Epidural compared with non-epidural analgesia and cardiopulmonary complications after colectomy: A retrospective cohort study of 20,880 patients using a national quality database. Journal of clinical anesthesia 2018; 47:12-18. https://doi.org/10.1016/j.jclinane.2018.03.005.

Guay J, Suresh S, Kopp S, Johnson R. Postoperative epidural analgesia versus systemic analgesia for thoraco-lumbar spine surgery in children. The Cochrane database of systematic reviews 2017; 1:CD012819. doi: 10.1002/14651858.CD012819.pub2.

Téoule P, Bartel F, Birgin E, Rückert F, Wilhelm TJ. The Clavien–Dindo classification in pancreatic surgery: a clinical and economic validation. J Invest Surg 2019; 32(4):314–20.

Kambakamba P, Slankamenac K, Tschuor C, Kron P, Wirsching A, Maurer K, Petrowsky H, Clavien P, Lesurtel M. Epidural analgesia and perioperative kidney function after major liver resection. British Journal of Surgery 2015; doi: 10.1002/bjs.9810.

Pratt WB, Maithel SK, Vanounou T, Huang ZS, Callery MP, Vollmer Jr CM. Clinical and economic validation of the International Study Group of Pancreatic Fistula (ISGPF) classification scheme. Ann Surg 2007; 245(3):443–51.

Kagedan DJ, Ahmed M, Devitt KS, Wei AC. Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB (Oxford) 2015; 17(1):11–6.

Simpson R, Simpson R, Fennerty M, Colgate C, Kilbane E, Ceppa E, Ceppa E, House M, Zyromski N, Nakeeb A, Schmidt C. Post-Pancreaticoduodenectomy Outcomes and Epidural Analgesia: A 5-year Single-Institution Experience. Journal of the American College of Surgeons 2019; 228(4): 453-462. doi: 10.1016/j.jamcollsurg.2018.12.038.

Zang H, Zhu L, Yan W. Relationship between Pleth Variability Index and the Occurrence of Hypotension during Epidural Anesthesia for Cesarean Section. J Coll Physicians Surg Pak 2021 Jun;31(6):619-622. doi: 10.29271/jcpsp.2021.06.619. PMID: 34102769.

Sugiura T, Uesaka K, Ohmagari N, Kanemoto H, Mizuno T. Risk factor of surgical site infection after pancreaticoduodenectomy. World J Surg 2012; 36:2888-94. doi: 10.1007/s00268-012-1742-6.

Wang BW, Mok KT, Chang HT, et al. APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer. J Am Coll Surg 1998; 187:287-94.

Markus PM, Martell J, Leister I, et al. Predicting postoperative morbidity by clinical assessment. Br J Surg 2005; 92:101-6.

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Published

2024-06-28

How to Cite

USENKO, O. Y., SIMONOV, O. M., & GURIN, P. V. (2024). THE USE OF PERIOPERATIVE EPIDURAL ANALGESIA AND THE OUTCOMES OF SURGICAL TREATMENT FOLLOWING PANCREATODUODENECTOMY: A CLINICAL STUDY. Hospital Surgery. Journal Named by L.Ya. Kovalchuk, (2), 5–13. https://doi.org/10.11603/2414-4533.2024.2.14840

Issue

No. 2 (2024)

Section

ORIGINAL INVESTIGATIONS

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