ASO Author Reflections: How Can We Improve the Postoperative Experience for Our Pancreatic Cancer Patients? A Practical
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: How Can We Improve the Postoperative Experience for Our Pancreatic Cancer Patients? A Practical Technique to Optimize Pain Control After Major Abdominal Surgery Ajay V. Maker, MD, FACS1,2 1
Division of Surgical Oncology, Department of Surgery, University of Illinois at Chicago, Chicago, IL; 2Creticos Cancer Center at Advocate Illinois Masonic Medical Center, Chicago, IL
PAST
PRESENT
Pain control after major hepatopancreaticobiliary (HPB) surgery traditionally employs opioid analgesia. Whether by intermittent injections or patient-controlled analgesia (PCA), short-acting opioids have been the mainstay of treatment. This approach is known to result in excess opioid consumption, potential narcotic dependence, respiratory depression, nausea, emesis, drowsiness, and delayed return of bowel function.1 As postoperative ileus and delayed gastric emptying are the main drivers of length of stay after pancreatic surgery, efforts to minimize opioid use and increase early ambulation have been at the forefront of enhanced recovery after surgery (ERAS) pathways. Epidural anesthesia is an important and popular pain control strategy that, when functioning well, can decrease narcotic use and improve pain control. Unfortunately, there remains conflicting and confusing data on the benefit of epidural analgesia after HPB surgery. The most recent ERAS Society guidelines reported a weak recommendation for the use of epidurals after pancreatic surgery2 and a strong recommendation against the use of epidural anesthesia in hepatic surgery.3 Thus, there is clearly a gap in knowledge of how to best provide adequate pain control after pancreatic surgery while minimizing opioids, particularly for cancer patients.
It was in this context that we began to explore techniques to utilize local anesthetics as a component of multimodal therapy. Epidurals with bupivacaine provided a nice pain control option, and, when they worked, they were invaluable; however, there are inconsistencies in their efficacy that can make the patient experience variable. Difficulty in initial placement can delay operative start times, and, even when functioning perfectly, the catheters are prone to becoming displaced or prone to malfunction, often ironically during the middle of the night or at other times difficult for anesthesia team assessment. Furthermore, epidural boluses address inadequate pain control but are often followed by hypotension requiring fluid boluses; this while trying to maintain euvolemia and minimize fluids in order to improve postoperative outcomes. Given the variability in patient and institutional experiences, it is thus not surprising that multiple studies have found length of stay and morbidity to be increased, decreased, or unaffected by the utilization of epidural analgesia after HPB surgery. We recently reported that epidurals were employed in 26% of pancreatic surgeries in North America, and were found to be associated with prolonged hospitalization and increased urinary tract infections aft
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