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      Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

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          Abstract

          Background

          The optimal analgesic technique after pancreatoduodenectomy remains under debate. This study aimed to see whether epidural analgesia (EA) has superior clinical outcomes compared with non‐epidural alternatives (N‐EA) in patients undergoing pancreatoduodenectomy.

          Methods

          A systematic review with meta‐analysis was performed according to PRISMA guidelines. On 28 August 2018, relevant literature databases were searched. Primary outcomes were pain scores. Secondary outcomes were treatment failure of initial analgesia, complications, duration of hospital stay and mortality.

          Results

          Three RCTs and eight cohort studies (25 089 patients) were included. N‐EA treatments studied were: intravenous morphine, continuous wound infiltration, bilateral paravertebral thoracic catheters and intrathecal morphine. Patients receiving EA had a marginally lower pain score on days 0–3 after surgery than those receiving intravenous morphine (mean difference (MD) −0·50, 95 per cent c.i. −0·80 to −0·21; P < 0·001) and similar pain scores to patients who had continuous wound infiltration. Treatment failure occurred in 28·5 per cent of patients receiving EA, mainly for haemodynamic instability or inadequate pain control. EA was associated with fewer complications (odds ratio (OR) 0·69, 95 per cent c.i. 0·06 to 0·79; P < 0·001), shorter duration of hospital stay (MD −2·69 (95 per cent c.i. −2·76 to −2·62) days; P < 0·001) and lower mortality (OR 0·69, 0·51 to 0 93; P = 0·02) compared with intravenous morphine.

          Conclusion

          EA provides marginally lower pain scores in the first postoperative days than intravenous morphine, and appears to be associated with fewer complications, shorter duration of hospital stay and less mortality.

          Translated abstract

          Antecedentes

          La técnica analgésica óptima tras una duodenopancreatectomía permanece en debate. El objetivo de este estudio fue analizar si la analgesia epidural ( epidural analgesia, EA) presenta resultados clínicos superiores en comparación con las alternativas no epidurales ( non‐epidural alternatives, N‐EA) en pacientes que se someten a una duodenopancreatectomía.

          Métodos

          Se realizó una revisión sistemática con metaanálisis de acuerdo con las recomendaciones PRISMA. El 28 de agosto de 2018, se realizó una búsqueda en las bases de datos relevantes de la literatura. El objetivo primario fueron las puntuaciones de dolor. Los objetivos secundarios fueron el fracaso del tratamiento de la analgesia inicial, las complicaciones, la duración de la estancia hospitalaria y la mortalidad.

          Resultados

          Se incluyeron tres ensayos aleatorizados y controlados y ocho estudios de cohortes (25.089 pacientes). Las N‐EA estudiadas fueron: morfina intravenosa (iv), infiltración continua de la herida, catéteres torácicos paravertebrales bilaterales y morfina intratecal. Los pacientes con EA tuvieron una puntuación de dolor marginalmente más baja en los días postoperatorios 0 a 3 en comparación con la morfina iv (diferencia de medias (MD) = ‐ 0,50, i.c. del 95% ‐0,80 a ‐0,21; P < 0,001) y puntuaciones de dolor similares en comparación con la infiltración continua de la herida. El fallo del tratamiento ocurrió en el 28,5% de los pacientes con EA, principalmente por inestabilidad hemodinámica o control inadecuado del dolor. La EA se asoció con menos complicaciones (razón de oportunidades, odds ratio, OR = 0,69, i.c. del 95% 0,061 a 0,79; P < 0,001), menor duración de la estancia hospitalaria (MD = ‐2,69 días, i.c. del 95% ‐2,76 a ‐2,62; P < 0,001) y menor mortalidad en comparación con la morfina iv (OR = 0,69, i.c. del 95% 0,51 a 0,93; P = 0,01).

          Conclusión

          La EA proporciona puntuaciones de dolor ligeramente más bajas en los primeros días postoperatorios en comparación con la morfina iv y parece asociarse con menos complicaciones, menor duración de la estancia hospitalaria y menor mortalidad.

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          Most cited references39

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          Severe neurological complications after central neuraxial blockades in Sweden 1990-1999.

          Central neuraxial blockades find widespread applications. Severe complications are believed to be extremely rare, but the incidence is probably underestimated. A retrospective study of severe neurologic complications after central neuraxial blockades in Sweden 1990-1999 was performed. Information was obtained from a postal survey and administrative files in the health care system. During the study period approximately 1,260,000 spinal blockades and 450,000 epidural blockades were administered, including 200,000 epidural blockades for pain relief in labor. : The 127 complications found included spinal hematoma (33), cauda equina syndrome (32), meningitis (29), epidural abscess (13), and miscellaneous (20). Permanent neurologic damage was observed in 85 patients. Incidence of complications after spinal blockade was within 1:20-30,000 in all patient groups. Incidence after obstetric epidural blockade was 1:25,000; in the remaining patients it was 1:3600 (P < 0.0001). Spinal hematoma after obstetric epidural blockade carried the incidence 1:200,000, significantly lower than the incidence 1:3,600 females subject to knee arthroplasty (P < 0.0001). : More complications than expected were found, probably as a result of the comprehensive study design. Half of the complications were retrieved exclusively from administrative files. Complications occur significantly more often after epidural blockade than after spinal blockade, and the complications are different. Obstetric patients carry significantly lower incidence of complications. Osteoporosis is proposed as a previously neglected risk factor. Close surveillance after central neuraxial blockade is mandatory for safe practice.
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            Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials.

            To quantify benefit and harm of epidural analgesia, compared with systemic opioid analgesia, in adults having surgery under general anesthesia.
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              • Article: not found

              Failed epidural: causes and management.

              Failed epidural anaesthesia or analgesia is more frequent than generally recognized. We review the factors known to influence the success rate of epidural anaesthesia. Reasons for an inadequate epidural block include incorrect primary placement, secondary migration of a catheter after correct placement, and suboptimal dosing of local anaesthetic drugs. For catheter placement, the loss of resistance using saline has become the most widely used method. Patient positioning, the use of a midline or paramedian approach, and the method used for catheter fixation can all influence the success rate. When using equipotent doses, the difference in clinical effect between bupivacaine and the newer isoforms levobupivacaine and ropivacaine appears minimal. With continuous infusion, dose is the primary determinant of epidural anaesthesia quality, with volume and concentration playing a lesser role. Addition of adjuvants, especially opioids and epinephrine, may substantially increase the success rate of epidural analgesia. Adjuvant opioids may have a spinal or supraspinal action. The use of patient-controlled epidural analgesia with background infusion appears to be the best method for postoperative analgesia.
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                Author and article information

                Contributors
                j.s.d.mieog@lumc.nl
                Journal
                BJS Open
                BJS Open
                10.1002/(ISSN)2474-9842
                BJS5
                BJS Open
                John Wiley & Sons, Ltd (Chichester, UK )
                2474-9842
                29 April 2019
                October 2019
                : 3
                : 5 ( doiID: 10.1002/bjs5.v3.5 )
                : 559-571
                Affiliations
                [ 1 ] Department of Surgery Leiden University Medical Centre Leiden the Netherlands
                [ 2 ] Department of Anaesthesiology Leiden University Medical Centre Leiden the Netherlands
                [ 3 ] Department of Surgery Amsterdam University Medical Centre Amsterdam the Netherlands
                Author notes
                [*] [* ] Correspondence to: Dr J. S. D. Mieog, Department of Surgery, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands (e‐mail: j.s.d.mieog@ 123456lumc.nl )
                Author information
                https://orcid.org/0000-0002-2438-4665
                https://orcid.org/0000-0001-9370-0011
                https://orcid.org/0000-0002-3649-8504
                Article
                BJS550171
                10.1002/bjs5.50171
                6773638
                31592509
                c4e7bf7d-7e8d-49a7-90f5-ae313f5abfa1
                © 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd

                This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.

                History
                : 02 January 2019
                : 01 March 2019
                Page count
                Figures: 7, Tables: 3, Pages: 13, Words: 4957
                Funding
                Funded by: Alpe d'HuZes foundation/Dutch Cancer Society
                Award ID: UL2015‐7665
                Categories
                Systematic Review
                Systematic Reviews
                Custom metadata
                2.0
                bjs550171
                October 2019
                Converter:WILEY_ML3GV2_TO_NLMPMC version:5.6.9 mode:remove_FC converted:01.10.2019

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