1. When compared to epidural pain control, patient controlled analgesia was associated with better outcomes and pain control in laparoscopic colorectal surgery patients.
2. Epidural analgesia slowed recovery without providing any additional benefit.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Pain control is one of the cornerstones of post-operative patient care. Evidence is mixed about the use of epidural devices for pain control in laparoscopic colorectal surgery patients. This study analyzed 128 patients who were randomized to either epidural analgesia (EDA) or patient controlled analgesia (PCA) and followed with an endpoint of medical recovery which was defined as: sufficient oral pain control, fully mobilized or comparable to pre-operative status, and tolerating oral intake requirements 2/3 of normal meal. PCA was associated with fewer complications, shorter hospital stays, less perioperative use of vasopressors, and no difference in pain scores post-operatively.
Strengths of this study included randomization, clearly defined endpoints and the use of intention-to-treat analysis to reduce bias. Weaknesses include the lack of power in the study with an initial goal of reaching statistical significance if >64 patients were enrolled in each arm of the study and on 57 patients were analyzed with PCA. Also the use of an enhanced recovery pathway itself may be a confounding variable that affected the outcome of EDA or PCA use because other perioperative pathways may have negated the benefit of PCA use.
In-Depth [randomized controlled trial]: Of the 266 patients initially evaluated, 128 met inclusion criteria and were randomized to either EDA or PCA. The 65 EDA patients and 57 PCA patients had similar baseline health status and demographics. Post-operative length of stay showed similar interquartile ranges of 3-7.5 for EDA and 3-6 for PCA (p=.082). Complications were significantly higher in the EDA group (54% vs 33%; p=.029). Vasopressor treatment at pre-op, day of operation and post-op day 1 were all significantly higher in the EDA group (90% vs 74%, P = 0.018, 27% vs 4%, P < 0.001, and 29% vs 4%, P < 0.001 respectively). The goal qualitative pain score was <4/10 and was assessed twice a day. EDA and PCA were discontinued according to the study protocol on POD 2 in 47 (72%) and 55 (96%) of patients, respectively (P = 0.005). Treatment time was significantly longer in the EDA group (2.33 ± 1.17 days vs 1.65 ± 0.66 days, P < 0.001). Other complications included 17% foley catheter re-insertion in the EDA group vs 11% in PCA group as well as 3 re-admissions from the EDA group versus no re-admissions in the PCA group. In summary, while length of stay may be similar, medical recovery and complication rates including vasopressor requirements are decreased using PCA in laparoscopic colorectal surgery in an enhanced recovery pathway.
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