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After Pancreatectomy Epidural Dysfunction Increases Postoperative Complications
Motokazu Sugimoto*, Joshua Barton, Louis W. Traverso
Center for Pancreatic and Liver Disease, St. Luke's Health System, Boise, ID
Introduction: Epidural analgesia can be effective to manage postoperative pain after major abdominal surgery. In a nationwide retrospective study by Amini et al. (Am J Surg 2012), epidural analgesia was associated with significantly lower postoperative complications and lower total charges after pancreaticoduodenectomy (PD). A higher incidence of post-PD complications was noted by Pratt et al. (J Gastrointest Surg 2008) if an epidural catheter had to be discontinued before postoperative day (POD) 4. The aim of this study was to seek if there is a relationship between dysfunctional epidural analgesia and complications after pancreatectomy - either pancreas-related or non-pancreas-related.
Methods: Between August 2010 and October 2014, 99 patients underwent pancreatectomy at the St. Luke's Health system. Nine patients who underwent laparoscopic pancreatectomy and 28 patients who did not receive epidural analgesia were excluded. Seventy-one patients (72%) who underwent open pancreatectomy with epidural analgesia were investigated (PD in 49 patients and distal pancreatectomy in 22 patients). Preoperatively thoracic epidural catheters were placed within the T5-T9 interspace level and patient-controlled epidural analgesia was started postoperatively. Epidural dysfunction was defined as either hypo-function or hyper-function. Hypo-function included epidural replacement due to inadequate pain control, conversion from epidural analgesia to intravenous patient-controlled analgesia ≤ POD 4, or intravenous bolus narcotics use ≤ POD 4. Hyper-function included hypotension or oliguria that required intravenous fluid bolus or reduction/discontinuation of epidural infusion.
Results: Of the 71 open pancreatectomy patients with epidural analgesia, the rates of complications were: overall complications 55%, pancreas-related complications 30% (such as pancreatic fistula and delayed gastric emptying), and non-pancreas-related complications 41%. Epidural dysfunction was observed in 49%: hypo-function in 35% and hyper-function in 14%. Significant independent prognostic factors after multivariate risk analysis were - overall complications (higher age as a continuous variable, P =0.021, men, P =0.030, and epidural dysfunction, P =0.004); pancreas-related complications (epidural dysfunction, P =0.045); and non-pancreas-related complications (higher age, P =0.018, and epidural dysfunction, P =0.002).
Conclusions: With half of our epidural analgesia attempts being successful an opportunity for statistical analysis emerged in 71 cases. Epidural dysfunction was related to the development of both pancreas-related and non-pancreas-related complications. The reason why epidural analgesia improves patient outcomes after pancreatectomy is multifactorial but improving an institution's success with epidural analgesia may be an opportunity to improve surgical outcomes.
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