Meta-analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

J V Groen, A A J Khawar, P A Bauer, B A Bonsing, C H Martini, T H Mungroop, A L Vahrmeijer, J Vuijk, A Dahan, J S D Mieog, J V Groen, A A J Khawar, P A Bauer, B A Bonsing, C H Martini, T H Mungroop, A L Vahrmeijer, J Vuijk, A Dahan, J S D Mieog

Abstract

Background: The optimal analgesic technique after pancreatoduodenectomy remains under debate. This study aimed to see whether epidural analgesia (EA) has superior clinical outcomes compared with non-epidural alternatives (N-EA) in patients undergoing pancreatoduodenectomy.

Methods: A systematic review with meta-analysis was performed according to PRISMA guidelines. On 28 August 2018, relevant literature databases were searched. Primary outcomes were pain scores. Secondary outcomes were treatment failure of initial analgesia, complications, duration of hospital stay and mortality.

Results: Three RCTs and eight cohort studies (25 089 patients) were included. N-EA treatments studied were: intravenous morphine, continuous wound infiltration, bilateral paravertebral thoracic catheters and intrathecal morphine. Patients receiving EA had a marginally lower pain score on days 0-3 after surgery than those receiving intravenous morphine (mean difference (MD) -0·50, 95 per cent c.i. -0·80 to -0·21; P < 0·001) and similar pain scores to patients who had continuous wound infiltration. Treatment failure occurred in 28·5 per cent of patients receiving EA, mainly for haemodynamic instability or inadequate pain control. EA was associated with fewer complications (odds ratio (OR) 0·69, 95 per cent c.i. 0·06 to 0·79; P < 0·001), shorter duration of hospital stay (MD -2·69 (95 per cent c.i. -2·76 to -2·62) days; P < 0·001) and lower mortality (OR 0·69, 0·51 to 0 93; P = 0·02) compared with intravenous morphine.

Conclusion: EA provides marginally lower pain scores in the first postoperative days than intravenous morphine, and appears to be associated with fewer complications, shorter duration of hospital stay and less mortality.

© 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.

Figures

Figure 1
Figure 1
PRISMA flow diagram for the review
Figure 2
Figure 2
Forest plot of pain scores following treatment with epidural anaesthesia versus non‐epidural anaesthesia. a Epidural anaesthesia (EA) versus intravenous (i.v.) morphine; b EA versus continuous wound infiltration (CWI). POD, postoperative day. *Values are mean(s.d.). An inverse‐variance fixed‐effect model was used for meta‐analysis. Mean differences (MDs) are shown with 95 per cent confidence intervals
Figure 3
Figure 3
Forest plot of overall complications, pneumonia, postoperative pancreatic fistula and ileus following treatment with epidural anaesthesia versus non‐epidural anaesthesia. EA, epidural anaesthesia; N‐EA, non‐epidural anaesthesia; i.v., intravenous; CWI, continuous wound infiltration. A Mantel–Haenszel fixed‐effect model was used for meta‐analysis. Odds ratios are shown with 95 per cent confidence intervals
Figure 4
Figure 4
Forest plot of duration of hospital stay following treatment with epidural anaesthesia versus non‐epidural anaesthesia. EA, epidural anaesthesia; N‐EA, non‐epidural anaesthesia; LOS, length of stay; i.v., intravenous; ITM, intrathecal morphine; BTPC, bilateral thoracic paravertebral catheter. *Values are mean(s.d.). An inverse‐variance fixed‐effect model was used for meta‐analysis. Mean differences (MDs) are shown with 95 per cent confidence intervals
Figure 5
Figure 5
Forest plot of mortality following treatment with epidural anaesthesia versus non‐epidural anaesthesia. EA, epidural anaesthesia; N‐EA, non‐epidural anaesthesia; i.v., intravenous; CWI, continuous wound infiltration; ITM, intrathecal morphine. A Mantel–Haenszel fixed‐effect model was used for meta‐analysis. Odds ratios are shown with 95 per cent confidence intervals
Figure 6
Figure 6
Funnel plots for all outcomes. a Pain scores for epidural anaesthesia (EA) versus intravenous (i.v.) morphine; b pain scores for EA versus continuous wound infiltration (CWI); c complications; d duration of hospital stay; e mortality. POD, postoperative day; MD, mean difference; OR, odds ratio; ITM, intrathecal morphine; BTPC, bilateral thoracic paravertebral catheter

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