Worse outcomes seen with epidural analgesia after elective ventral hernia repair

Reuters Health Information: Worse outcomes seen with epidural analgesia after elective ventral hernia repair

Worse outcomes seen with epidural analgesia after elective ventral hernia repair

Last Updated: 2017-03-31

By Will Boggs MD

NEW YORK (Reuters Health) - Postoperative epidural analgesia does not appear to improve pain control and may worsen several outcomes in patients undergoing elective ventral hernia repair, according to a new study.

"As with all new findings, time will tell if our findings are reproducible,” Dr. Ajita S. Prabhu from The Cleveland Clinic Foundation, in Cleveland, Ohio, told Reuters Health by email. “At my institution, our team has stopped using epidurals for the time being, and then after a period of time we will reassess to see if indeed our length of stay is improved.”

Epidural analgesia is commonly used to manage perioperative pain after various types of surgery, but it has not been thoroughly investigated for ventral hernia repair.

Dr. Prabhu and colleagues used data from the Americas Hernia Society Quality Collaborative to evaluate the association of postoperative epidural analgesia with hospital length of stay, 30-day wound morbidity, postoperative complications, and patient-reported postoperative quality of life in 763 propensity score-matched pairs of patients (half of whom received postoperative epidural analgesia and half of whom did not).

Pain scores were significantly higher in the epidural group than in the non-epidural group (47.6 vs. 44.0, p=0.04), the researchers report in the Annals of Surgery, online March 10.

The group that received epidurals had an increased mean length of stay (5.49 vs. 4.90 days for non-epidurals, p<0.05) and an increased risk of having any postoperative complication (26% vs. 21%, p<0.05).

The two groups did not differ in their risks of surgical site occurrence, surgical site occurrence requiring procedural intervention, surgical site infection or quality of life. The incidence of renal failure was lower in the group receiving epidurals than in the non-epidural group, however (0% vs. 0.7%, p<0.05).

“Our findings suggest that the benefits of epidurals noted in other bodies of literature may not be broadly applicable to patients undergoing ventral hernia repair,” the researchers conclude.

“Additional studies are needed to determine patient satisfaction, impact on immediate postoperative pain, and appropriate population for postoperative epidurals after ventral hernia. Further study is necessary to determine the most clinically effective and cost-effective modality for pain management in this group of patients with an extremely common disease state,” they add.

“Sometimes our foregone conclusions are exactly that,” Dr. Prabhu said. “We have to be able to objectively examine our biases and then be willing to change practice where it makes sense.”

“Our findings certainly bring up other questions about postoperative pain management in ventral hernia patients,” she added. “For instance, have we been selecting for patients who already have greater baseline pain to receive epidurals? If we standardized the management of epidurals, would we have a different finding? Is there a subgroup of patients that can still benefit from epidural analgesia? Is there an alternative standardized protocol, such as transverse abdominis plane (TAP) blocks and/or multimodal strategies, that may be equally as effective or more effective? I think the time is certainly here for us to carefully evaluate and consider these questions with an open mind.”

Dr. Lars Nannestad Jorgensen from the University of Copenhagen, in Denmark, has investigated various aspects of abdominal wall repair (AWR). He told Reuters Health by email, “Large registry studies are great tools for monitoring of clinical practice across centers and detection of rare events. However, the clinical importance, even though statistically significant, of the mean difference of length of stay and pain intensity between the groups (0.61 days and 3.6 out of hundred, respectively) is perhaps questionable.”

“The patient demographics suggest that most of these hernia repairs were complex because of high rates of comorbidity, obesity, and need for myofascial release,” he said. “It is surprising that the present results conflict with data from meta-analyses regarding pain, postoperative ileus, and length of stay.”

“Data from our center has shown that epidural analgesia is an important part of an enhanced recovery after surgery (ERAS) protocol that facilitates reduction of length of stay to a median of 3 days after AWR, which was the case for less than 25% of the patients in present material,” he said.

“The findings of this large registry study emphasize the need for more randomized studies to prospectively determine the effects and indications for postoperative epidural analgesia in AWR,” Dr. Jorgensen concluded.

SOURCE: http://bit.ly/2nD3ABB

Ann Surg 2017.

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