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Introduction: Over the past decade, epidural analgesia and anesthesia (EAA) has become the preferred method of pain management for major abdominal surgery. With regards to pancreaticoduodenectomy (PD), the superior form of analgesia, as evidenced by their respective non-analgesic outcomes, has been debated. In this study, we compare postoperative morbidity and mortality with EAA and IV analgesia in patients who underwent PD. We also examine preoperative factors that lead to epidural discontinuation and the consequence of premature epidural discontinuation on morbidity and mortality.
Methods: A retrospective review of a prospective database of PDs performed at a single institution was conducted for the time period between January 2007 and July 2011. Patients receiving IV analgesia (group A) were compared with patients receiving EAA alone or in conjunction with IV analgesia (group B). Endpoints included mortality, major postoperative complications, postoperative hypotension, postoperative fluid requirements, length of stay, and hospital readmission within 30 days. Multivariate logistic regression was performed to measure the predictive success of epidural analgesia in comparison to IV analgesia for each endpoint, as well as to measure the predictive success of preoperative parameters including age, gender, BMI, surgical indication, and comorbidity. Using these same preoperative parameters, Classification and regression tree (CART) analysis for predictive modeling was used to determine predictors of epidural failure. Chi-Squared analysis was also performed to compare patients who had epidural failure with the rest of group B using the previously assessed morbidity and mortality endpoints.
Results: Of the 163 patients reviewed, 14 (9%) were in group A and 149 (91%) were in group B. Endpoints were similar between the two groups, however 22 patients (15%) in group B had their epidural discontinued early due to either severe hypotension or epidural malfunction. Within this group, patients older than 72 and with a BMI less than or equal to 20 had their epidural discontinued in 80% of cases compared with 12% of patients not meeting this criteria. There was no significant difference in endpoints between the 22 patients that had their epidural discontinued prematurely and the other 127 patients in group B who did not require premature epidural discontinuation.
Conclusion: EAA may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction. However, premature epidural discontinuation was not associated with increased morbidity and mortality. Prospective randomized trials are warranted to further determine if EAA should be avoided in this specific population.