S. S. Kim1, X. Niu1, I. A. Elliott1, J. P. Jiang1, A. M. Dann1, L. M. Damato1, H. Chung1, M. D. Girgis1, J. C. King1, O. J. Hines1, S. Rahman1, T. R. Donahue1 1David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA
Introduction: Epidural analgesia (EA) is frequently used after pancreatic surgery for postoperative pain control and offers many benefits over intravenous narcotics. However, there is inconsistent evidence on the effect of EA on postoperative hospital length of stay (LOS), expeditious discharge, and pain control in patients undergoing pancreatic surgery.
Methods: A retrospective review of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2014 to 2015 was conducted to determine the effect of EA on LOS after open pancreatic surgery with multiple logistic regression analysis. A single-institution pancreas surgery database was also reviewed to determine the impact of EA on patient-reported postoperative pain.
Results: There were 6185 patients who underwent open pancreaticoduodenectomy (PD) and 1913 patients who underwent open distal pancreatectomy (DP) in the 2014-2015 ACS-NSQIP databases. The frequencies at which patients were administered EA were 23.2% for PD and 19.4% for DP. EA was associated with a statistically significant longer median LOS for both PD and DP (p= 0.007, 0.001 respectively). There was a significantly greater proportion of patients with EA discharged after 5 to 8 days for PD and 5 to 9 days for DP. A detailed comparative analysis was conducted for patients discharged before vs. after 7 days for PDs and 6 days for DPs, as they were the most frequent LOS for these procedures and generally represent an efficient and complication-free postoperative course. There were significantly more patients who received EAs in the longer LOS groups for both procedures (PD: 24.5% vs. 18.3%, p< 0.001, DP: 21.3% vs. 15.5%, p= 0.001). On multivariable analysis controlling for pancreatectomy-relevant complications, EA remained significant for the longer groups for both PD and DP (PD: OR 1.465, p< 0.001, DP: OR 1.417, p= 0.004). On review of single-institution pancreas surgery database, patient-reported pain scores were significantly lower in the EA groups (PD: n= 20, DP: n= 24) than intravenous narcotics groups (PD: n= 20, DP: n= 18) on the day of surgery only (PD: p= 0.008, DP: p= 0.031).
Conclusion: Epidural analgesia impeded early discharge after surgery for patients undergoing open PD and DP in the 2014-2015 ACS-NSQIP databases. EA led to improved pain control only on the day of surgery in our institutional database. Based on these results, we suggest an earlier transition from EA to intravenous and oral opioids so as to not delay an early discharge, provided pain is well-controlled and the patient appears to be on course for an uncomplicated recovery.