Thoracic epidural analgesia vs. patient-controlled intravenous analgesia for patients undergoing open or laparoscopic colorectal cancer surgery

Abstract

BACKGROUND Thoracic epidural analgesia (TEA) is an invasive technique with potential side effects but is widely used in enhanced recovery after surgery (ERAS) programmes in colorectal cancer surgery. The effects of TEA on postoperative length of hospital stay (LOS) or morbidity is still debated. OBJECTIVES The main objective was to evaluate the postoperative analgesic effectiveness of TEA compared with patient-controlled intravenous analgesia (PCIA) after open or laparoscopic colorectal surgery, and whether TEA contributes to enhanced recovery. DESIGN A retrospective single-centre, observational study. SETTING Dutch tertiary-care university hospital. PATIENTS All consecutive adult patients undergoing colorectal cancer surgery from 1 January 2014 to 31 December 2016, with ASA status I-IV, were included. Exclusion criteria were hypersensitivity to opioid or local anaesthetic substances, or the use of multiple secondary anaesthetic techniques. MAIN OUTCOME MEASURES The primary outcome, postoperative pain assessed with a Numeric Rating Scale on postoperative days 1 to 3 inclusive. Secondary endpoints were LOS, the incidence of epidural related side effects, major complications and the 5-year survival rate. Using linear mixed models, pain scores were compared between patients who received TEA and PCIA. RESULTS Of 422 enrolled patients, 110 (32%) received TEA and 234 (68%) PCIA. Patients in the TEA group had lower pain scores: estimated NRS difference at rest; -0.79; 95% CI, -1.1 to -0.49; P < 0.001 and during movement -1.06; 95% CI, -1.39 to -0.73; P < 0.001. LOS, 30-day complication rate and overall survival at 5 years did not differ between the groups. CONCLUSIONS TEA in open or laparoscopic colorectal surgery is associated with moderately better postoperative pain control but does not affect LOS, postoperative morbidity, mortality nor long-term survival. The current clinical indication for TEA in colorectal surgery remains unchanged. TRIAL REGISTRATION International clinical trial registration number: ISRCTN11426678; retrospectively registered 26 February 2021.