Epidural Analgesia for Pancreatoduodenectomy: A Critical Appraisal

Introduction  Epidural analgesia has emerged as a commonly applied method to improve pain management and reduce perioperative complications in major abdominal surgery. However, there is no detailed analysis of its efficacy for pancreatic operations. This study compares clinical and economic outcomes after epidural and intravenous analgesia for pancreatoduodenectomy. Material and methods  Data for 233 consecutive patients, who underwent pancreatoduodenectomy, were prospectively acquired and retrospectively reviewed at a single institution, pancreato-biliary specialty practice. From October 2001 to February 2007, all patients were offered thoracic epidural analgesia, and those who declined received intravenous analgesia. Perioperative pain management was dictated as an element of a standardized clinical pathway for pancreatic resections. Clinical and economic outcomes were analyzed and compared for epidural analgesia and intravenous analgesia groups. Results  One hundred eighty-five patients received epidural analgesia, and 48 received intravenous analgesia, with equivalent baseline patient demographics between the groups. Patients administered epidural analgesia had lower pain scores but significantly higher rates of major complications. Pancreatic fistulae and postoperative ileus occurred more frequently, and patients with epidural analgesia more often required discharge to rehabilitation facilities. A trend towards longer hospitalizations was observed among epidural analgesia patients, but total costs were statistically equivalent between the groups. Further analysis demonstrates that 31% of epidural infusions were aborted before anticipated (fourth postoperative day) because of hemodynamic compromise and/or inadequate analgesia. These select patients required more transfusions, aggressive fluid resuscitation, and subsequently suffered even higher rates of gastrointestinal and respiratory complications, all attributing to higher costs. Multivariate analysis demonstrates that preoperative hematocrit concentration less than 36%, elderly age (>75 years), and chronic pancreatitis predict failure of epidural infusions. Conclusion  Thoracic epidural analgesia after pancreatic resections is associated with hemodynamic instability, which may compromise enteric anastomoses, gastrointestinal recovery, and respiratory function. These outcomes are exacerbated in poorly functioning epidurals and suggest that epidural analgesia may not be the optimal method for perioperative pain control when pancreatoduodenectomy is performed. Presented at the 7th World Congress of the International Hepato-Pancreato-Biliary Association, Edinburgh, Scotland, September, 3–7, 2006. Presented at the 2006 Annual Meeting of the American Society of Anesthesiologists, Chicago, IL, October 14–18, 2006.     

Qualitätsverbesserung durch multimodale postoperative Therapie

Effects of anaesthesia and analgesia on postoperative morbidity and mortality remain controversial. Numerous studies have demonstrated that epidural anaesthesia and pain relief by epidural analgesia reduces perioperative stress responses and thus may reduce postoperative morbidity and mortality. In patients undergoing vascular surgery, epidural anaesthesia diminished postoperative hypercoagulability. These patients may benefit from less thromboembolic complications as well as a reduced risk of a re-operation. However, regional anaesthesia does not affect cardiopulmonary morbidity or overall mortality significantly in most clinical studies. One reason for this disappointing finding may be the missing integration of improved postoperative pain relief into general surgical care. A multimodal therapeutic approach, which consists of preoperativ patient information, sufficient analgesia, early mobilisation and enteral feeding, may solve this discrepancy. Therefore, prospective controlled studies are needed to assess the influence of this perioperative approach on outcome.     

Effect of epidural anesthesia and analgesia on perioperative outcome: a randomized, controlled Veterans Affairs cooperative study

OBJECTIVE: To test the hypothesis that epidural anesthesia and postoperative epidural analgesia decrease the incidence of death and major complications during and after four types of intraabdominal surgical procedures. SUMMARY BACKGROUND DATA: Even though many beneficial aspects of epidural anesthesia have been reported, clinical trials of epidural anesthesia for outcome of surgical patients have shown conflicting results. METHODS: The authors studied 1,021 patients who required anesthesia for one of the intraabdominal aortic, gastric, biliary, or colon operations. They were assigned randomly to receive either general anesthesia and postoperative analgesia with parenteral opioids (group 1) or epidural plus light general anesthesia and postoperative epidural morphine (group 2). The patients were monitored for death and major complications during and for 30 days after surgery, as well as for postoperative pain, time of ambulation, and length of hospital stay. RESULTS: Overall, there was no significant difference in the incidence of death and major complications between the two groups. For abdominal aortic surgical patients, unlike the other three types of surgical patients, the overall incidence of death and major complications was significantly lower in group 2 patients (22%) than in group 1 patients (37%), stemming from differences in the incidence of new myocardial infarction, stroke, and respiratory failure between the two groups. Overall, group 2 patients received significantly less analgesic medication but had better pain relief than group 1 patients. In group 2 aortic patients, endotracheal intubation time was 13 hours shorter and surgical intensive care stay was 3.5 hours shorter. CONCLUSIONS: The effect of anesthetic and postoperative analgesic techniques on perioperative outcome varies with the type of operation performed. Overall, epidural analgesia provides better postoperative pain relief. Epidural anesthesia and epidural analgesia improve the overall outcome and shorten the intubation time and intensive care stay in patients undergoing abdominal aortic operations.     

Epidurale Analgesie in der Behandlung postoperativer Schmerzen Eine Übersicht

This review highlights the advantages of regional anaesthesia techniques, especially of epidural analgesia, for the management of postoperative and posttraumatic pain: excellent pain relief and a high degree of patient satisfaction, even compared to the gold standard of acute pain therapy, i.v. PCA with opioids. Further advantages of epidural analgesia (EA) are discussed, such as early recovery of gastrointestinal function, reduction of postoperative respiratory complications, lower incidence of myocardial ischema, better mobilisation, reduced risk of thromboembolism, lower incidence of chronic pain problems (such as phantom limb pain) etc. Nevertheless, many studies failed to show significant effects on outcome (e.g. mortality). Weighing the risks, costs and benefits of EA, this technique is indicated in case of significant postoperative pain, especially in case of painful mobilisation, in patients with significant pulmonary risk factors (ASA 3 or IV), in patients where an improved perfusion or gastrointestinal motility is deemed essential, and if chronic pain syndromes are common problems that should be prevented (e.g. amputation). For the praxis of epidural analgesia it is emphasised to place the catheter in an appropriate segment to obtain sufficient analgesia without side effects. Organisational structures (such as an acute pain service) and appropriate monitoring allow to continue EA with local anaesthetics and/or opioids on surgical wards. Recommendations are given for the monitoring of EA on surgical wards. Clear cut agreements should define the role of anaesthesiologists, surgeons and nurses in the management of patients treated with postoperative EA on surgical wards.     

Personal experience of pancreas reconstruction following pancreaticoduodenectomy

BACKGROUND: This study was designed to evaluate the surgical outcomes of an alternative method of pancreaticojejunostomy and pancreaticogastrostomy according to the size of the remnant pancreatic duct following pancreaticoduodenectomy. METHODS: Eighty-four patients who underwent pancreaticoduodenectomy by the same surgeon were retrospectively reviewed from February 1997 to December 2004. Pancreaticojejunostomy for large remnant pancreatic ducts (>5 mm in diameter) and pancreaticogastrostomy for smaller remnant pancreatic ducts (<5 mm in diameter) were alternately carried out by the surgeon. Patients' perioperative data were evaluated. RESULTS: The size of the remnant pancreatic duct was significantly different between the pancreaticojejunostomy and pancreaticogastrostomy groups (7.2 +/- 4.3 mm vs 2.9 +/- 1.6 mm, P < 0.001). Pancreaticojejunostomy was carried out in 27 patients (33.3%) and pancreaticogastrostomy was carried out in 51 patients (66.7%). The mean operation time was 327 +/- 67.4 min and the mean duration of the hospital stay was 25.5 +/- 9.1 days. Pancreatic leakage was found in 10 patients (12.3%) without leading to mortality and was successfully treated by temporary restriction of oral intake and conservative management. None of the patients required an additional surgical procedure for pancreatic leak. Other postoperative complications were unremarkable when compared with previous results. One case of massive bleeding found in the pancreaticogastrostomy group required surgical intervention. CONCLUSION: Pancreaticogastrostomy and pancreaticojejunostomy according to the size of the remnant pancreatic duct can be an alternative strategy to maintain the postoperative rate of pancreatic leak within an acceptable range without hospital mortality related to this complication.     

Patient controllediv analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia

PURPOSE: To examine the hypothesis that pain treatment with patient controlled analgesia (PCA) using iv morphine is a suitable and safe alternative to epidural analgesia in morbidly obese patients undergoing gastric bypass surgery. We retrospectively compared the postoperative periods in all patients undergoing this procedure in our institution between November 1999 and November 2001. METHODS: According to their perioperative pain treatment, patients were assigned to a PCA group (with iv morphine) or an epidural analgesia group, in which patients received either intermittent doses of morphine or continuous infusions of bupivacaine/fentanyl. Study endpoints included quality of pain control, incidence of cardiovascular and respiratory complications, analgesia related side effects, time to ambulation and first flatus, length of hospital stay, and wound infections. RESULTS: Data from 86 patients were analyzed with 40 patients in the PCA group and 46 patients in the epidural group. Groups were similar with respect to age, body mass index, and gender. The type of analgesia did not affect the quality of pain control at rest, the frequency of nausea and pruritus, the time to ambulation and return of gastrointestinal function, and the length of hospital stay. Patients receiving epidural analgesia had a greater risk of wound infection than subjects with PCA (epidural group: 39%, PCA group: 15%, P = 0.01). CONCLUSION: We conclude that in grossly obese patients undergoing gastric bypass surgery PCA with iv morphine is an acceptable strategy for pain management and may confer some advantages when compared to epidural analgesia.     

A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer

OBJECTIVE: A prospective randomized controlled trial (RCT) of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. AIMS: This study evaluates the use of a multimodal package in colorectal cancer surgery in the context of an RCT. METHODS: Patients for elective resection for colorectal cancer were offered trial entry. Participants were stratified by sex and requirement for a total mesorectal excision and centrally randomized. Multimodal patients received intravenous fluid restriction, unrestricted oral intake with prokinetic agents, early ambulation, and fixed regimen epidural analgesia. Control patients received intravenous fluids to prevent oliguria, restricted oral intake until return of bowel motility, and weaning regimen epidural analgesia. Adherence to both regimens was reinforced using a daily checklist and protocol guidance sheets. Discharge decision was made using pre-agreed criteria. The primary endpoint was postoperative stay, and achievement of independence milestones. Secondary endpoints were postoperative complications, readmission rates, and mortality. Analysis was by intention to treat. RESULTS: Seventy patients were recruited. Approximately one fourth underwent TME. Median ages were similar (69.3 vs. 73.0 years). The median stay was significantly reduced in the multimodal group (5 vs. 7 days; P < 0.001, Mann-Whitney U test). Patients in the control arm were 2.5 times as likely to require a postoperative stay of more than 5 days. Patients in the multimodal group had less cardiorespiratory and anastomotic complications but more readmissions. There were 2 deaths, both controls. CONCLUSIONS: This RCT provides level 1b evidence that a multimodal management protocol can significantly reduce postoperative stay following colorectal cancer surgery. Morbidity and mortality are not increased.     

加速康复外科在腹腔镜胰十二指肠切除术围手术期管理中的临床应用

目的:探讨加速康复外科(ERAS)在腹腔镜胰十二指肠切除术围手术期管理中的临床应用价值。方法:选取2016年1月至2019年1月收治的168例行腹腔镜胰十二指肠切除术的患者,采用随机数字法分为ERAS组与对照组,ERAS组围手术期采取ERAS措施,对照组采取常规围手术期处理。对比分析两组术后恢复情况、术后并发症发生情况、术后住院时间、住院费用、再次手术率及病死率。结果:ERAS组首次肛门排气时间、进食时间、胃管留置时间、腹腔引流管与尿管拔除时间、疼痛、住院费用、身体质量指数优于对照组,差异均有统计学意义(P<0.05),两组术后总体并发症发生率、胰瘘与腹腔出血情况、再手术、再入院、病死率差异无统计学意义(P>0.05)。结论:腹腔镜胰十二指肠切除术围手术期应用ERAS措施可促进患者术后快速康复,缩短住院时间,降低住院费用,安全性高。     

The role of epidural anesthesia and analgesia in surgical practice

OBJECTIVE: To review the potential and proven benefits and complications of epidural anesthesia/analgesia. SUMMARY BACKGROUND DATA: Advances in analgesia/anesthesia have improved patient satisfaction and perioperative outcomes. Epidural anesthesia/analgesia is one of these advances that is gaining rapid acceptance due to a perceived reduction in morbidity and overall patient satisfaction. METHODS: A MEDLINE search was conducted for all pertinent articles on epidural anesthesia/analgesia. RESULTS: Retrospective, prospective, and meta-analysis studies have demonstrated an improvement in surgical outcome through beneficial effects on perioperative pulmonary function, blunting the surgical stress response and improved analgesia. In particular, significant reduction in perioperative cardiac morbidity ( approximately 30%), pulmonary infections ( approximately 40%), pulmonary embolism ( approximately 50%), ileus ( approximately 2 days), acute renal failure ( approximately 30%), and blood loss ( approximately 30%) were noted in our review of the literature. Potential complications related to epidural anesthesia/analgesia range from transient paresthesias (<10%) to potentially devastating epidural hematomas (0.0006%). CONCLUSIONS: Epidural anesthesia/analgesia has been demonstrated to improve postoperative outcome and attenuate the physiologic response to surgery.     

Postoperative outcome of open donor nephrectomy under epidural analgesia: a descriptive analysis

PURPOSE: Patients subjected to open donor nephrectomy with epidural analgesia were analyzed to determine whether there was a relation between catheter placement site and the appearance of complications and satisfactory analgesia and to determine whether this factor had an impact upon recovery and return to preoperative life. METHODS: A cohort of 36 open donor nephrectomies were performed with postoperative epidural analgesia. Two groups were analyzed: thoracic (22 patients) and lumbar catheters (14 patients). There was a 72-hour evaluation followed by phone contact. Besides detecting related complications pain was evaluated using a visual analog scale (VAS 0 to 10) in the postanesthesia care unit and at 6, 24, 48 and 72 hours postoperatively. Satisfactory analgesia was defined as a VAS of 3 or less. RESULTS: In all cases the analgesic solution was composed of bupivacaine 0.125% with an opioid in 97%. Patients showed complications in 72% (26/36); the only significant association was motor blockade in the lumbar group (21% vs 0% in the thoracic, P = .023). Patients had a mean VAS of 2.83 +/- 1.77. There was a larger proportion of pain-free patients (VAS 0) in the thoracic group; in addition, there was no VAS of 10 in this group. Ambulation was resumed in less than 24 hours in 57% of patients, having a mean VAS of 2.1 +/- 1.5 compared with 3.2 +/- 1.6 among those who ambulated after 24 hours (P = .04). There was no association between perioperative pain control and the interval to normal activities. CONCLUSIONS: Without a control group, we can hardly evaluate the impact of epidural analgesia on perioperative outcome. Notwithstanding, the obtained pain control may justify its use in these patients. An important issue is to maintain a low VAS (<3), especially in the first 24 hours, which may make a clinically important difference for early ambulation.     

Negligible Effect of Perioperative Epidural Analgesia Among Patients Undergoing Elective Gastric and Pancreatic Resections

Background

There are conflicting data regarding improvements in postoperative outcomes with perioperative epidural analgesia. We sought to examine the effect of perioperative epidural analgesia vs. intravenous narcotic analgesia on perioperative outcomes including pain control, morbidity, and mortality in patients undergoing gastric and pancreatic resections.

Methods

We evaluated 169 patients from 2007 to 2011 who underwent open gastric and pancreatic resections for malignancy at a university medical center. Emergency, traumatic, pediatric, enucleations, and disseminated cancer cases were excluded. Clinicopathologic data were reviewed among epidural (E) and non-epidural (NE) patients for their association with perioperative endpoints.

Results

One hundred twenty patients (71 %) received an epidural and 49 (29 %) did not. There were no significant differences (P?>?0.05) in mean pain scores at each of the four days (days 0–3) among the E (3.2?±?2.7, 3.2?±?2.3, 2.3?±?1.9, and 2.1?±?1.9, respectively) and NE patients (3.7?±?2.7, 3.4?±?1.9, 2.9?±?2.1, and 2.4?±?1.9, respectively). Within each of the E and NE patient groups, there were significant differences (P?<?0.0001) in mean pain scores from day 0 to day 3 (P?<?0.0001). Of the E patients, 69 % also received intravenous patient-controlled analgesia (PCA). Ileus (13 % E vs. 8 % NE), pneumonia (12 % E vs. 8 % NE), venous thromboembolism (6 % E vs. 4 % NE), length of stay [11.0?±?12.1 (8, 4–107) E vs. 12.2?±?10.7 (7, 3–54) NE], overall morbidity (36 % E vs. 39 % NE), and mortality (4 % E vs. 2 % NE) were not significantly different.

Conclusions

Routine use of epidurals in this group of patients does not appear to be superior to PCA.     

Impact of anesthesia technique on the incidence of major complications after open aortic abdominal surgery: a cohort study

Study ObjectiveTo determine the risk factors of perioperative complications and the impact of intrathecal morphine (ITM) in major vascular surgery.DesignRetrospective analysis of a prospective cohort.SettingsOperating room, intensive care unit, and Postanesthesia Care Unit of a university hospital.MeasurementsData from 595 consecutive patients who underwent open abdominal aortic surgery between January 1997 and December 2011 were reviewed. Data were stratified into three groups based on the analgesia technique delivered: systemic analgesia (Goup SA), thoracic epidural analgesia (Group TEA), and intrathecal morphine (Group ITM). Preoperative patient characteristics, perioperative anesthetic and medical interventions, and major nonsurgical complications were recorded.Main ResultsPatients managed with ITM (n=248) and those given thoracic epidural analgesia (n=70) required lower doses of intravenous (IV) sufentanil intraoperatively and were extubated sooner than those who received systemic analgesia (n=270). Total inhospital mortality was 2.9%, and 24.4% of patients experienced at least one major complication during their hospital stay. Intrathecal morphine was associated with a lower risk of postoperative morbidity (OR 0.51, 95% CI 0.28 - 0.89), particularly pulmonary complications (OR 0.54, 95% CI 0.31 - 0.93) and renal dysfunction (OR 0.52, 95% CI 0.29 - 0.97). Other predictors of nonsurgical complications were ASA physical status 3 and 4 (OR 1.94, 95% CI 1.07 - 3.52), preoperative renal dysfunction (OR 1.61, 95% CI 1.01 - 2.58), prolonged surgical time (OR 1.78, 95% CI 1.16 - 2.78), and the need for blood transfusion (OR 1.77, 95% CI 1.05 - 2.99).ConclusionsThis single-center study showed a decreased risk of major nonsurgical complications in patients who received neuraxial analgesia after abdominal aortic surgery.     

Complications after pancreaticoduodenectomy for pancreatic cancer: a retrospective study

Postoperative complications, such as pancreatic fistulae, after pancreaticoduodenectomy for pancreatic cancers are associated with surgical outcomes of patients with pancreatic cancers. A total of 160 patients with pancreatic cancers undergoing pancreaticoduodenectomy were retrospectively analyzed. Patients were grouped into a fistulae group (n = 34) and a nonfistulae group (n = 126). The fistulae group had a significantly higher morbidity rate than the nonfistulae group (P < 0.0001), but hospital mortality was not different in both groups (P = 0.481). There was a higher incidence of intra-abdominal hemorrhage in patients with pancreatic fistulae than in those without fistulae. Two patients in fistulae group underwent reoperation. Patients with pancreatic fistulae had significantly longer hospital stay than those without fistulae. Pancreatic duct diameter, smoking, years of tobaccos consumption, preoperative jaundice, and surgical hours were associated with risk of fistulae on univariate analysis. In a multivariate analysis, diameter of pancreatic duct, surgical hours, and preoperative jaundice were independent risk factors of pancreatic fistulae. Incidence of pancreatic fistulae after pancreaticoduodenectomy is significantly influenced by the size of pancreatic duct diameter, surgical time, and preoperative jaundice. Early postoperative hemorrhage could be cautiously prevented. The survival is not significantly impacted by pancreatic fistulae.     

Does a thoracic epidural confer any additional benefit following video-assisted thoracoscopic pleurectomy for primary spontaneous pneumothorax?

OBJECTIVE: Video-assisted thoracoscopic (VATS) bullectomy and apical pleurectomy has become the preferred procedure for recurrent or complicated primary spontaneous pneumothorax (SPN). Although thoracic epidural analgesia is the gold standard after open thoracic surgical procedures, its use in the management of minimally invasive procedures in this young population has not been extensively studied. METHODS: From 1997 to 2003, a single surgeon performed 118 consecutive VATS pleurectomies for primary SPN. The perioperative course, analgesic requirements, hospital stay and long-term complications were compared for 22 (18%) patients in whom a patient-controlled thoracic epidural was used for analgesia and 96 (82%) patients who did not receive an epidural (parenteral opioids). A four-point verbal pain score (0-3) was recorded hourly in every patient at rest and on coughing following surgery. RESULTS: One patient required additional surgery for evacuation of haemothorax. There were no mortalities or other major complications in the series. Overall median hospital stay was 3 (range 1-10) days, the incidence of long-term pain at 3 months was 6%, and the long-term recurrence rate was 3%. Despite parenteral opioids being discontinued significantly earlier than epidurals, pain scores were similar in both groups. There were no significant differences in the duration of air-leaks, length of drainage, hospital stay, long-term pain and long-term paraesthesias between the two groups. CONCLUSIONS: Thoracic epidural analgesia does not contribute significantly to minimize neither perioperative nor long-term pain after VATS pleurectomy for primary SPN. The additional resource requirement in these patients is not justified.     

Epidural analgesia in thoracic surgery--optimising postoperative rehabilitation

INTRODUCTION: A multimodal perioperative therapy strategy (fast-track) decreases the morbidity of general thoracic interventions and increases postoperative reconvalescence after lung resections. Thoracic surgery is associated with relevant pain and sufficient pain relief is essential for postoperative recovery. Epidural analgesia leads to adequate pain control with only minor side effects and complications and can therefore be a reasonable supplementation in a modern fast-track setting. The purpose of this study was to evaluate the benefits and risks of an epidural catheter placed prior to surgery and to analyse the postoperative recovery of patients undergoing thoracic surgery. METHODS: 277 patients undergoing pulmonary resection through an anterolateral thoracotomy were included in our study. Epidural analgesia was carried out through placement of an epidural catheter equipped with Naropine-Sufenta perfusor prior to surgery. Perioperative clinical parameters as well as postoperative management were evaluated. Pain intensity was documented using the visual analogue scale (VAS). Side effects and complications were summarised in five grades of severity (1-5). Insufficient pain relief was recognised when a VAS > 4 was registered. RESULTS: Median patient age was 59 years, the male / female relation was precisely 2 : 1, on average epidural analgesia was carried out for 4.9 days. Severe complications (grade 4 or 5) were not found. In 37 % of the cases, minor complications and side effects were found, in 1 % clinical relevant complications led to further diagnostic measures. For sufficient pain relief, 10 % of the studied population needed additional treatment with systemic opioids. CONCLUSION: We have shown that epidural analgesia in patients undergoing thoracotomy leads to sufficient pain control with only minor disadvantages and complications. These are easily mastered without expensive diagnostic or therapeutic interventions. Therefore, epidural analgesia is a safe and helpful tool for increased postoperative recovery within a modern fast-track setting.     

Surgical complications following pancreaticoduodenectomy: results of a single center experience

Pancreaticoduodenectomy represents the only therapeutic option for cefalo-pancreatic and periampullary cancers. Surgical and anaesthesiological techniques development over the last twenty years has granted an operative mortality decrease. However, surgical morbidity is still high, with an incidence of 30-50%. A 20 year experience of a single Centre is examined retrospectively: 121 patients underwent pancreatic resection with radical intent. Type of operation or re-operation, operative mortality within 30 days, general and surgical morbidity, postoperative hospital stay were analysed. Average recovery time was 24 days (range 12-65); operative mortality was 5.8% (7/121); general morbidity, including medical and surgical complications, was observed in 47 patients (38.8%). Pancreatic fistula occurred in 16 patients (13.2%); ten of these underwent a second operation. Patients who underwent pancreaticoduodenctomy were divided as follows: 76 pts. received a pylours-preserving pancreaticoduodenectomy and 45 a Whipple's resection. Neither surgical complications incidence nor mortality rate were significantly different between the two groups. Postoperative complications following pancreaticoduodenectomy are still frequent and severe. In particular, pancreatic fistula represents the most relevant complication following pancreaticoduodenectomy. The Authors suggest that standard and meticulous surgical procedures together with continued efforts to improve postoperative follow-up, support early detection of complications and improvement of results in most patients.     

Chronic pain management: American Society of Anesthesiologists Closed Claims Project

BACKGROUND: The practice of chronic pain management has grown steadily in recent years. The purpose of this study was to identify and describe issues and trends in liability related to chronic pain management by anesthesiologists. METHODS: Data from 5,475 claims in the American Society of Anesthesiologists Closed Claims Project database between 1970 and 1999 were reviewed to compare liability related to chronic pain management with that related to surgical and obstetric (surgical/obstetric) anesthesia. Acute pain management claims were excluded from analysis. Outcomes and liability characteristics between 284 pain management claims and 5,125 surgical/obstetric claims were compared. RESULTS: Claims related to chronic pain management increased over time (P < 0.01) and accounted for 10% of all claims in the 1990s. Compensatory payment amounts were lower in chronic pain management claims than in surgical/obstetric anesthesia claims from 1970 to 1989 (P < 0.05), but during the 1990s, there was no difference in size of payments. Nerve injury and pneumothorax were the most common outcomes in invasive pain management claims. Epidural steroid injections accounted for 40% of all chronic pain management claims. Serious injuries, involving brain damage or death, occurred with epidural steroid injections with local anesthetics and/or opioids and with maintenance of implantable devices. CONCLUSIONS: Frequency and payments of claims associated with chronic pain management by anesthesiologists increased in the 1990s. Brain damage and death were associated with epidural steroid injection only when opioids or local anesthetics were included. Anesthesiologists involved in home care of patients with implanted devices such as morphine pumps and epidural injections or patient-controlled analgesia should be aware of potential complications that may have severe outcomes.     

Epidural morphine analgesia compared with intravenous morphine for oral cancer surgery with pectoralis major myocutaneous flap reconstruction

BACKGROUND: Oral cancer surgery with reconstruction is a complex operative procedure with morbidities such as respiratory complications and post-operative pain. These morbidities may be reduced with appropriate operative and post-operative pain management. Epidural analgesia provides better pain control than intravenous opioids after major thoraco-abdominal surgical procedures. We planned to undertake a prospective study to compare the efficacy and side-effects of epidural morphine analgesia vs. intravenous morphine in patients undergoing oral cancer surgery with pectoralis major myocutaneous flap reconstruction. METHODS: Sixty patients undergoing a major surgical procedure for oral cancer with pectoralis major myocutaneous flap reconstruction were prospectively randomized to receive either epidural morphine or intravenous morphine in the post-operative period. The intensity of pain was assessed daily using a 100-mm visual analogue scale. The post-operative side-effects, time to ambulation, time to tolerate first nasogastric feed, total length of hospital stay and global satisfaction score were recorded. RESULTS: The epidural morphine group had statistically significant lower pain scores at the three evaluation times through the post-operative 48 h (P < 0.05). However, the mean visual analogue scores were always below 35 in the intravenous morphine group. Patients in the epidural morphine group ambulated and accepted nasogastric feed significantly earlier than those in the intravenous morphine group. The incidence of nausea/vomiting or pruritus, the length of hospital stay and the global satisfaction score were not statistically different between the groups. CONCLUSION: This study illustrates that epidural morphine offers better pain control than intravenous morphine after oral cancer surgery with pectoralis major myocutaneous flap reconstruction. Nevertheless, both methods appear to provide very good pain relief, and perhaps the extra risks inherent to epidural catheter insertion are not outweighed by the benefits in this type of surgery.     

Pylorus-preserving pancreaticoduodenectomy versus conventional pancreaticoduodenectomy for pancreatic adenocarcinoma

Purpose  A few randomized controlled trials have questioned the justification of pylorus-preserving pancreaticoduodenectomy (PpPD) for pancreatic cancer and periampullary cancer. However, the characteristics of pancreatic cancer are remarkably different from those of other periampullary cancers, so the outcomes of PD and PpPD for pancreatic cancer are being re-evaluated. Methods  We studied retrospectively, 55 patients who underwent PpPD at Wakayama Medical University Hospital between 1999 and 2005, when PpPD was available, for pancreatic head adenocarcinoma. The main outcome measures were the postoperative complications, mortality, and survival of the patients who underwent PpPD vs. those who underwent conventional pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma. Results  There were no significant differences between PD and PpPD in postoperative complications; however, the incidences of delayed gastric emptying (DGE) differed significantly according to the type of reconstruction (P < 0.01). The body weight ratio and the incidence of diarrhea 6 months after PpPD and PD were similar. Patients treated with PD had a higher duodenal invasion rate than those treated with PpPD (P < 0.05); therefore, the cause-specific survival of the PpPD patients was better than that of the PD patients (P < 0.05). Conclusion  The surgical outcomes and incidence of postoperative complications in this series suggest that PpPD is an appropriate surgical procedure for pancreatic adenocarcinoma.