G. G. Kasumova1, O. Tabatabaie1, S. Logarajah1, A. Fadayomi1, S. Ng1, J. F. Tseng1 1Beth Israel Deaconess Medical Center,Surgical Outcomes Analysis & Research, Department Of Surgery,Boston, MA, USA
Introduction: Epidurals are frequently utilized during major abdominal surgery in attempt to improve postoperative analgesia and outcomes. Epidural analgesia is also an integral part of enhanced recovery regimens. However, results surrounding their use in pancreatectomy are conflicting. We evaluated a large modern cohort of patients undergoing pancreatectomy to assess the effect of epidural utilization on perioperative outcomes.
Methods: Retrospective review of patients undergoing pancreatectomy for any indication in 2014 using the targeted ACS-NSQIP database. Patients with disseminated cancer, non-elective or emergency procedures were excluded from analysis. Characteristics were compared via chi-square and Wilcoxon rank sum test. LOS and thirty day morbidity were evaluated.
Results: A total of 4398 patients underwent pancreatectomy with 846 (19.2%) undergoing epidural placement. Epidurals were more likely to be placed during open vs. laparoscopic procedures (22.2% vs. 10.1%, p<0.0001). Black patients were least likely to have an epidural placed (16.8% vs. 18.6% for white vs. 25.0% for other, p=0.0007). There were no differences in age, sex, ASA class or BMI. Patients with epidurals were more likely to have delayed gastric emptying (13.9% vs. 10.2%, p=0.007), UTI (4.7% vs. 3.2%, p=0.035), postoperative bleeding (19.7% vs. 15.6%, p=0.004), and pancreatic fistula (20.6% vs. 16.7%, p=0.014). There were no differences between groups of pneumonia, DVT, other major complication, and 30 day mortality. Operative time was significantly longer in those with additional epidural anesthesia, median of 339 minutes (IQR: 258, 439) vs. 305 minutes (IQR: 210.5, 401). Postoperative LOS was significantly longer in patients with epidural placement, median 8 (IQR: 6, 11) vs. 7 (IQR: 5, 10). On subset analysis, 1566 patients underwent proximal pancreatectomy with 337 (21.5%) receiving an epidural; there were no differences in postoperative major morbidity and LOS. Of 1287 patients who underwent distal pancreatectomy, 170 (13.2%) received an epidural; those with epidural had significantly longer LOS median 6 (IQR: 5, 8) vs. 5 (IQR: 4, 7).
Conclusion: Addition of epidural anesthesia did not affect major perioperative morbidity, but did demonstrate prolonged LOS. Patients receiving epidural analgesia may be less likely to receive adequate pain control postoperatively leading to delayed mobilization and prolonged admission. Surgeons may also select patients for epidural placement based on anticipated procedure complexity. Further evaluation will need to evaluate type of analgesic to determine its utility and potential role in enhanced recovery regimens following pancreatectomy, as well as potential implications for reimbursement.
