Baylor University Medical Center Proceedings July 2017 - 255

Effects of epidural analgesia on recovery after open
colorectal surgery
Ahmad Elsharydah, MD, MBA, Leila W. Zuo, MD, Abu Minhajuddin, PhD, and Girish P. Joshi, MBBS, MD

The use of epidural analgesia (EA) has been suggested as an integral part
of an enhanced recovery program for colorectal surgery. However, the effects of EA on postoperative outcomes and hospital length of stay remain
controversial. Data from the American College of Surgeons National
Surgical Quality Improvement Program database for 2014 and 2015
were queried for adult patients who underwent elective open colorectal
surgery. We included only cases with general anesthesia as the main
anesthetic. Cases with other types of anesthesia were excluded. A 1:3
matched sample of EA versus non-EA cases was created based on
propensity scores. The primary outcome of interest was the occurrence
of major cardiopulmonary complications within 7 days of the surgery.
Secondary outcome measures were hospital length of stay and 30-day
mortality. A total of 24,927 patients were included in the analysis. EA was
utilized in 15.02% (n = 3745). The cumulative risk over the study period
for major cardiopulmonary complications was 2.52% (n = 627). There
were no statistically significant differences in the rate of postoperative
complications (relative risk 0.91, 95% CI 0.66-1.27, P = 0.59), length
of stay (median [interquartile range], EA 6 [5-9] versus non-EA 6 [4-9]
days, P = 0.36), and 30-day mortality rate (relative risk 0.71, 95% CI
0.42-1.20, P = 0.20) between the two propensity-matched cohorts. In
conclusion, our study revealed that the benefits of EA in patients undergoing open colorectal surgery are limited, as it does not influence immediate
postoperative cardiopulmonary complications or hospital length of stay.

dequate dynamic pain control is a critical component
of an enhanced recovery after surgery (ERAS) pathway
(1-3). Epidural analgesia (EA) has been suggested as an
integral part of an ERAS protocol for open colorectal
surgery because it provides excellent dynamic pain relief (2, 4).
However, several studies have revealed conﬂicting results with
regard to the beneﬁts of EA (5-8). A systematic review of randomized controlled trials (RCTs) concluded that in the setting
of an ERAS program, EA does not improve recovery or reduce
postoperative morbidity after open abdominal surgery (7). In
contrast, another systematic review found that EA reduced the
hospital length of stay (LOS), but the quality of evidence was
low (8). The concerns with these systematic reviews are that
the RCTs included in these analyses are older, which may not
represent current rapidly changing perioperative care for open
abdominal colorectal surgery (5). Therefore, we evaluated the
Proc (Bayl Univ Med Cent) 2017;30(3):255-258

eﬀects of EA on the incidence of major postoperative cardiopulmonary complications, hospital LOS, and 30-day mortality after open colorectal surgery using the American College
of Surgeons National Surgical Quality Improvement Program
(ACS-NSQIP) database. We hypothesized that use of EA is
associated with a reduced rate of postoperative cardiopulmonary
complications (the primary outcome measure).
METHODS
Data for 2014 and 2015 were obtained from the ACSNSQIP database, which provides multicenter, outcome-oriented
data that are prospectively and rigorously collected by dedicated
personnel (9). These data are collected from participating US
and international hospitals (with 603 participating sites up to
2015). At each hospital, a surgical clinical reviewer, using a
standardized and strict protocol, extracts information for welldeﬁned variables, including preoperative comorbidities and
laboratory data, patients' demographics, procedure-related and
intraoperative information, and 30-day postoperative morbidity and mortality. The ACS-NSQIP auditing and systematic
sampling processes are designed to ensure the collection of highquality data with minimized bias. Details regarding the ASCNSQIP sampling, auditing, inclusion, and exclusion processes
have been published (10). The ACS-NSQIP consists of publicly
available, deidentiﬁed data, and thus the study was considered to
be exempt from review by the University of Texas Southwestern
Medical Center, Dallas, Texas, Institutional Review Board.
Adult patients (18 years or older) who underwent elective
open colorectal surgery identiﬁed using current procedural
terminology codes were included in the analyses. Laparoscopic,
robotic-assisted, outpatient, and emergent cases were excluded,
as were any cases that involved preoperative sepsis, disseminated
cancer, or the need for ventilator support. We included only
cases with general anesthesia as the main anesthetic.
From the Department of Anesthesiology and Pain Management (Elsharydah,
Zuo, Minhajuddin, Joshi) and Department of Clinical Sciences (Minhajuddin), The
University of Texas Southwestern Medical Center, Dallas, Texas.
Corresponding author: Ahmad Elsharydah, MD, MBA, Department of
Anesthesiology and Pain Management, University of Texas Southwestern Medical
Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9068 (e-mail: ahmad.
elsharydah@utsouthwestern.edu).
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Table of Contents for the Digital Edition of Baylor University Medical Center Proceedings July 2017