Epidural analgesia in the era of enhanced recovery: time to rethink its use?

Abstract

Previous assessments of the impact of epidural analgesia (EA) on outcomes after colorectal surgery were related to the period before widespread implementation of the enhanced recovery after surgery (ERAS) protocols. This study evaluates the impact of EA on postoperative recovery after colectomy using recent multicenter data. Patients who underwent elective colectomy from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) data (2014-2015) were identified. Demographics, comorbidities, diagnosis, procedure type and approach, and postoperative complications associated with EA were assessed. Impact of EA on postoperative ileus, length of stay (LOS), and prolonged LOS (defined as LOS > 75 percentile) was evaluated for all, open, and laparoscopic cases using univariable and multivariable analyses. Of 9045 elective colectomy procedures, 3081 (34.1%) received EA. Epidural analgesia was associated with greater rates of postoperative ileus (15.9% vs. 10.8%, p < 0.0001), superficial (5.5% vs. 4%, p = 0.001) and deep (1.8% vs. 0.6%, p < 0.0001) wound infections, pulmonary embolism (0.8% vs. 0.4%, p = 0.004), deep vein thrombosis (1.3% vs. 0.7%, p = 0.01), sepsis/septic shock (4.6% vs. 3.1%, p < 0.0001), unplanned reintubation (1.5% vs. 0.8%, p = 0.003), cardiac complications (1.2% vs. 0.7%, p = 0.03), and transfusion (9.1% vs. 5.9%, p < 0.0001). Postoperative length of stay (LOS) [mean (SD), days: 6.7(6.2) vs. 5(4.5) days, p < 0.0001] was greater for EA. On multivariable analysis, EA had no impact on postoperative ileus for all and laparoscopic cases. However, EA increased the likelihood for ileus (OR 1.34, 95% CI 1.02-1.78) after open colectomy alone. Similarly, EA did not influence prolonged LOS for all and laparoscopic cases but was independently associated with prolonged LOS after open colectomy (OR 1.4, 95% CI 1.1-1.8). Epidural analgesia was not associated with improved recovery after elective colectomy in the era of ERAS.