Adv Ther. 2008:25(1):45–52. DOI:10.1007/s12325-008-0005-2
Efficacy of Thoracic Epidural Analgesia for Laparoscopic Cholecystectomy Demet Doğan Erol Kocatepe University, School of Medicine, Department of Anaesthesiology and Reanimation, Afyon, Turkey Sezgin Yilmaz Coskun Polat Yuksel Arikan Kocatepe University, School of Medicine, Department of General Surgery, Afyon, Turkey
ABSTRACT Introduction: Postoperative pain is a commonly observed phenomenon after laparoscopic procedures. The use of new low-solubility inhalation anaesthetics leads to faster induction and recovery, but the effect of analgesics on pain when used with them is not sufficiently known. Optimally, analgesic therapy should be started in sufficient time as to be effective at the point of emergence from anaesthesia. We compared the effectiveness of intravenous and epidural analgesia in patients undergoing general anaesthesia with sevoflurane for laparoscopic cholecystectomy in the early postoperative period. Methods: Thirty adult patients with American Society of Anesthesiologists (ASA) physical status I–II, scheduled for laparoscopic cholecystectomy, were enrolled in this study. The patients in the intravenous group (n=15) received general anaesthesia with sevoflurane and intravenous infusion of 1.5 μg/ml/kg/h fentanyl analgesia followed by postoperative intravenous infusion of 1.0 μg/ml/kg/h fentanyl, supplied by a programmed continuous analgesia pump. The patients in the epidural group (n=15) had combined epidural analgesia with 0.125% bupivacaine plus 50 μg fentanyl and general anaesthesia with sevoflurane, followed by continuous epidural infusion of 4 ml/h bupivacaine 0.125% plus 50 μg fentanyl. Visual analogue scores and the patients’ needs for analgesics and were recorded. Address correspondence to: Demet Doğan Erol, Dumlupinar Mah, Huseyin Tevfik Cad no 11/8, 03200 Afyon, Turkey. Email:
[email protected]
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Results: Epidural analgesia with a bupivacaine/fentanyl combination provided a statistically and clinically significant improvement in postoperative pain control compared with intravenous analgesia during the first 24 h following laparoscopic cholecystectomy. Conclusion: The epidural technique provided a significant effect on postoperative pain in patients undergoing laparoscopic cholecystectomy. Keywords: epidural analgesia; general anaesthesia; intravenous analgesia; laparoscopic cholecystectomy; sevoflurane
physical status classification and scheduled for laparoscopic cholecystectomy, were randomly divided into 2 groups with 15 patients in each. Any individuals with morbid obesity or a history of anticoagulation drug use were excluded. Full consent from the hospital ethics committee was provided and informed consent was obtained from each patient. Before the induction of the anaesthetic medication the patients were instructed on the use of a 10-cm-long visual analogue rating scale (VAS), with 0 cm identifying no pain and 10 cm the worst imaginable pain. The sedative midazolam (0.03 mg/kg) was administered intravenously to all patients 10 min prior to operation. In the epidural group an epidural catheter was inserted and 0.125% bupivacaine plus 50 μg fentanyl were administered using the ‘loss of resistance’ technique following determination of T11–12 epidural space. Patients underwent standard monitoring including electrocardiogram, arterial pressure, fraction of inspired oxygen (FIO2), end-tidal carbon dioxide concentration in the expired air (ETCO2), airway pressure, PerSaO2 and urine output. The epidural catheter was kept in place after the procedure. During the procedure, mild hypotension was corrected with intravenous ephedrine 5–10 mg.
INTRODUCTION Laparoscopic techniques have gained wide acceptance for various kinds of surgical procedures because of their beneficial effect on postoperative recovery and hospital stay. However, postoperative pain is a commonly observed phenomenon after laparoscopic procedures.1,2 The use of new low-solubility inhalation anaesthetics leads to faster induction and recovery, but the effect of analgesics on pain when used with these low-solubility anaesthetics is not sufficiently known. Laparoscopic cholecystectomy is a short surgical procedure,2 often less than 1 h. Optimally, analgesic therapy should be started in sufficient time to be effective at the point of emergence from anaesthesia. The aim of this study was to compare the effectiveness of intravenous and epidural analgesia in patients undergoing general anaesthesia with sevoflurane for laparoscopic cholecystectomy in the early postoperative period. MATERIALS AND METHODS In this study, 30 patients between the ages of 18 and 60 years, with an American Society of Anesthesiologists (ASA) I–II 46
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All patients were induced with 2–3 mg/kg propofol, 1.5 μg/kg fentanyl and intubated with 0.1 mg/kg vecuronium bromide. Anaesthesia was maintained with sevoflurane in concentration providing an average of 2–3 minimal alveolar concentration (MAC) value together with 50% air/ O2 ventilation in all patients, respectively. In the intravenous group (n=15), analgesia was maintained by fentanyl infusion 1.0 μg/ml/kg/h, and in the epidural group (n=15) by an epidural infusion of 4 ml/h bupivacaine 0.125% plus 50 μg fentanyl. In all cases 4 mg intravenous ondansetron was administered 5 min before the extubation, and nausea/vomiting prophylaxis was carried out. The decurarisation was provided by neostigmine 0.01 mg/kg and atropine 0.01 mg/kg to minimise the risk of residual neuromuscular blockage after the operation. VAS scores and the patients’ needs for analgesics were recorded at 15-, 30-, 60-, 90- and 120-min intervals and also evalu-
ated at 24 and 48 h postoperatively. Patients feeling pain were asked to identify the level of their pain on a scale of 0–10. Side effects such as nausea, vomiting, sedation, pruritus, urinary retention and motor block were determined by asking the patient or self-reporting by the patient. The epidural catheters were removed 48 h after surgery. Statistical evaluations were made using SPSS (SPSS 14.0 for Windows). Descriptive statistics were carried out to analyse the demographic variables, effect of anaesthesia and surgery duration. Statistics were performed using analysis of variance (pairedsample t test). Significance was determined at P0.05) (Table 1).
Table 1. Patient demographics (mean±standard deviation). Epidural group
Intravenous group
(n=15)
(n=15)
P value
Age, y
51.80±12.87
45.33±11.80
0.269
Weight, kg
77.06±07.13
79.13±12.08
0.539
Height, cm
162.53±10.16
160.66±05.05
0.424
2/13
0.189
Gender, male/female Surgery time, min Anaesthesia time, min
5/10 63.33±03.43
62.86±04.05
0.770
104.86±12.35
102.20±11.74
0.527
P>0.05 indicates no statistically significant difference.
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Figure 1. Pain scores. VAS=visual analogue rating scale. 6
Epidural group
VAS scores
5
Intravenous group
4 3 2 1 0 15 min 30 min 60 min 90 min 120 min
24 h
48 h
Time postoperatively
cystectomy is complex in nature. In laparoscopic cholecystectomy, overall pain is a conglomerate of 3 different and clinically separate components: incisional pain (somatic pain), visceral pain (deep intra-abdominal pain), and shoulder pain (presumably referred visceral pain).2,3 Its occurrence can increase due to peritoneal irritation by residual carbon dioxide. Pain is most intense on the day of surgery and on the following day, and subsequently declines to low levels within 3–4 d. However, pain may remain severe in approximately 13% of patients throughout the first week after laparoscopic cholecystectomy.2,3 In 17%–41% of the patients, pain is the main reason for staying overnight in hospital on the day of surgery, and pain is the dominating complaint and the primary reason for prolonged convalescence after laparoscopic cholecystectomy.3–5 Nausea and vomiting are particularly troublesome after laparoscopic surgery; more than 50% of patients require
As seen in Figure 1 at 15, 30, 60, 90 and 120 min and 24 and 48 h postoperatively, mean pain scores in the epidural group (00.16±00.31) were lower than those in the intravenous group (03.13±01.75) (P=0.002). Epidural and intravenous analgesia were well tolerated; adverse events such as nausea/vomiting, pruritus, urinary retention and motor block did not occur in all the patients. Epidural analgesia with a bupivacaine/fentanyl combination provided a statistically and clinically significant improvement in postoperative pain control compared with intravenous analgesia during the first 24 h following laparoscopic cholecystectomy. Compared with intravenous analgesia, the epidural group had a lower incidence of nausea/vomiting and sedation but a higher incidence of pruritus, urinary retention and motor block. DISCUSSION Acute pain after laparoscopic chole48
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compared with controls.14–17 There is safety, cost-benefit, and analgesic superiority in the use of laparoscopic cholecystectomy in healthy patients. The effect of timing on analgesia has not been studied in laparoscopic cholecystectomy. Epidural analgesia probably provides effective control of pain after laparoscopic cholecystectomy. Continuous epidural infusion have provided statistically significantly superior analgesia versus patientcontrolled epidural analgesia for overall pain, pain at rest, and pain with activity. Almost without exception, epidural analgesia, regardless of analgesic agent, epidural regimen, and type and time of pain assessment, provides superior postoperative analgesia compared to intravenous patient-controlled analgesia.14–17 These analgesic benefits, along with other potential benefits, should be weighed against the risks of epidural analgesia when considering the route of delivery for postoperative analgesia, and the balance between these risks and benefits should be determined for each surgical patient.18–30 Epidural anaesthesia has been used for outpatient gynaecological laparoscopic procedures to reduce complications and shorten recovery time after anaesthesia.31 Local or regional anaesthetic techniques have not been reported for laparoscopic cholecystectomy or other upper abdominal surgical procedures.32 Perhaps the ‘minimally invasive’ revolution will advocate earlier patient recovery and the increased implementation of regional anaesthetic techniques. The extent of the surgical stress response may be attenuated, ultimately minimising the inflammatory response. As with all new innovations, that kind of analge-
anti-emetics, so prophylactic anti-emetics may be given routinely.6 Therefore, we administered ondansetron to all patients 5 min before extubation. Ideally, analgesic therapy should be started in time to be effective at the point of emergence from anaesthesia. Laparoscopic cholecystectomy is a short surgical procedure,2 often less than 1 h. The effect of analgesics on pain when used with low-solubility inhalation anaesthetics is not sufficiently known. Opioids reduce pain by decreasing local inflammation at the trauma site and in the dorsal horn by activating inhibitory pathways to the descending spinal segments.7,8 The valuable analgesic properties of opioids in the treatment of acute, intense postoperative pain after major and minor surgery are well accepted.9 However, to hasten recovery and minimise opioidrelated side effects (somnolence and sedation, nausea and vomiting, sleep disturbances, urinary retention, and respiratory depression), prophylactic use of opioids in postoperative pain is avoided.2,10–12 Epidural local anaesthetics work by blocking afferent nerve activity at the spinal level. The efficacy of postoperative epidural analgesia in major surgical procedures is well established.13 All forms of epidural analgesia (both continuous epidural infusion and patient-controlled epidural analgesia) have been shown to provide significantly superior postoperative analgesia compared with intravenous patientcontrolled analgesia. Trials on laparoscopic cholecystectomy have suggested significant analgesic benefits with epidural analgesia and intrathecal morphine/local anaesthesia 49
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sic procedure will eventually ameliorate the postoperative period of patients by decreasing the pain response. The hypothesis that severe acute pain after laparoscopic cholecystectomy predicts development of chronic pain (such as post-laparoscopic cholecystectomy syndrome) should be investigated in future, well-defined, prospective, large-scale studies.33 In this randomised controlled trial, we examined the analgesic efficacy of postoperative epidural analgesia compared with intravenous analgesia. As a conclusion, epidural analgesia with a bupivacaine/fentanyl combination provided a statistically and clinically significant improvement in postoperative pain control compared with intravenous analgesia during the first 24 h following laparoscopic cholecystectomy. Our results suggest that there is a need for adequate analgesia in the early postoperative period after laparoscopic cholecystectomy, and continued epidural analgesia following surgery using easy-tofollow dosage regimens to facilitate.
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Bisgaard T. Analgesic treatment after laparoscopic cholecystectomy: a critical assessment of the evidence. Anesthesiology. 2006;104:835–846.
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Bisgaard T, Klarskov B, Rosenberg J, Kehlet H. Factors determining convalescence after uncomplicated laparoscopic cholecystectomy. Arch Surg. 2001;136:917–921.
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Nathanson LK, Shimi S, Cuschieri A. Laparoscopic cholecystectomy: the Dundee technique. Br J Surg. 1991;78:155–159.
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Quay H. Opioids in pain management. Lancet. 1999;353:2229–2232.
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Stein C. The control of pain in peripheral tissue by opioids. N Engl J Med. 1995;332:1685–1690.
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ACKNOWLEDGEMENTS The authors thank the residents, nurses and staff in the Ahmet Necdet Sezer Hospital (School of Medicine, Kocatepe University, Afyon, Turkey) for their multiple contributions. REFERENCES 1.
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