Abstract
Introduction: Enhanced recovery after surgery was developed to optimise peri-operative care in an attempt to accelerate recovery, reduce morbidity and shorten hospital stay. The use of epidural analgesia is considered fundamental in Enhanced Recovery Protocols (ERP). However its value in the peri-operative management of laparoscopic colorectal surgical patients is unclear, and current analgesic regimens vary. Previous studies addressing this issue have not been conducted within a full ERP and have not ensured that patients are fluid optimised. The aim of this study was to examine the effects of different analgesic regimes on outcomes following laparoscopic colorectal surgery in fluid optimised patients treated within an ERP. Methods: Two studies were performed. In the first study, ninety-nine patients undergoing laparoscopic colorectal segmental resections that did not involve the formation of a defunctioning stoma were randomised to receive epidural, spinal or patient controlled analgesia (PCA). Intra-operatively, all patients were fluid optimised using an oesophageal Doppler to guide fluid replacement according to the modified Wakeling protocol. All patients were treated within a full ERP. The primary end points were time until medically fit and the length of hospital stay. The secondary end points included the return of bowel function, pain scores and a quality of life assessment using the SF-36 questionnaire. The second study used the analgesic modality with the best results from the study above and assessed the safety and feasibility of patients being discharged within 23 hours from the start of laparoscopic colorectal surgery. Results: Ninety-one patients completed the study with the main exclusions being for open conversion and epidural failure. There were no differences in the patient demographics other than patient weight, which was higher in the PCA group. The use of epidural analgesia resulted in a significantly longer time until medically fit for discharge, a longer hospital stay and a slower return of bowel function than spinal and PCA. Pain scores were higher in the PCA group than the spinal and epidural group although this did not affect the quality of life scores, which were similar for all analgesic modalities. Using spinal analgesia, 10 patients were safely discharged home within 23 hours of their surgery without any complications or re-admissions. Discussion: The ERP has increasingly been used for laparoscopic surgery in its un-modified form with thoracic epidural use being a key feature. Many of the outcomes in the epidural analgesia group were significantly worse than the spinal and PCA groups suggesting that either of these two modalities could replace epidural analgesia. Although the results of the spinal and PCA groups were very similar, the pain scores and the return of bowel function were slightly better in the spinal group thereby lending itself to the analgesic modality of choice for patients treated along 23-hour stay pathway. In order to safely discharge patients home within 23 hours from the commencement of surgery, it is essential to ensure that patients are optimized at every point of their care pathway and fluid therapy appears to play a major factor in patient outcome.