Sex-appropriate pain management with epidural anesthesia in pancreaticoduodenectomy: a propensity score-matched analysis

Abstract

Presenter: Jorge G Zarate Rodriguez MD | Washington University, St. Louis Background: Pancreaticoduodenectomy (PD) is a complex procedure with significant morbidity and mortality. Enhanced-recovery pathways aimed at improving outcomes are common and often include epidural anesthesia, but data are mixed as to the effect of epidurals on postoperative outcomes. We hypothesized the impact of epidural anesthesia on postoperative outcomes would differ between sexes, with increased incidence of complications in male patients. Methods: Patients undergoing PD were prospectively followed, and their complications graded using the Modified Accordion Grading System (MAGS). Complications were categorized as non-severe if MAGS 1-2 and severe if MAGS ≥3. Patient factors and perioperative outcomes for patients with and without epidurals were compared in univariate and multivariate analysis. One-to-one propensity score matching was performed for all patients, as well as for male and female patients separately. Results: 565 patients underwent PD in the study period, 50.8% had epidural anesthesia. Compared to patients without epidurals, patients with epidurals were older (65.4 vs 63.4 years, p = 0.038), had longer operative times (p < 0.001) and lower intraoperative blood loss (p < 0.001). In terms of surgical outcomes, patients with epidurals had higher rates of MAGS non-severe delayed gastric emptying (18.5% vs 12.2%, p = 0.040) and urinary retention (16.0% vs 9.4%, p = 0.017). On multivariate analysis, epidural was independently associated with urinary retention (OR 2.03, p = 0.019), while female sex was protective (OR 0.51, p = 0.014). Propensity-score matched patients (171 pairs) had no statistically significant differences in demographic characteristics. Propensity-score matched patients with epidurals were more likely to have suffered MAGS severe complications (33.3% vs 22.8%, p = 0.030), urinary retention (15.2% vs 7.0%, p = 0.016), and DVT (10.5% vs 4.1%, p = 0.022), compared to matched patients without epidurals. Propensity-score matching was repeated separately by sex (male pairs = 85, female pairs = 76). Male propensity-score matched patients with epidurals were more likely to suffer MAGS non-severe delayed gastric emptying (29.4% vs 16.5%, p = 0.045) and urinary retention (21.2% vs 7.1%, p = 0.008) compared to matched patients without epidurals. There were no differences in postoperative outcomes for propensity-score matched female patients with and without epidurals. Conclusion: Epidural anesthesia was independently associated with urinary retention after PD, specifically in male patients. Enhanced-recovery pathways are not “one size fits all.” Further research should focus on tailoring these pathways to bridge sex disparities in clinical outcomes.