Gastrointestinal Motility Following Thoracic Surgery: The Effect of Thoracic Epidural Analgesia

A Randomised Controlled Trial

Argyro Zoumprouli; Aikaterini Chatzimichali; Stamatios Papadimitriou; Alexandra Papaioannou; Evaghelos Xynos; Helen Askitopoulou

Disclosures

BMC Anesthesiol. 2017;17(139) 

In This Article

Background

Impairment of gastrointestinal (GI) motility is an undesirable but inevitable consequence of abdominal or other surgery that delays recovery and may prolong hospital stay.[1,2] This effect, referred to as postoperative ileus (POI), is defined as a transient disruption of the normal coordinated movements of the gut preventing the effective transit of the intestinal contents to varying degrees.[3] The aetiology of this functional, non-mechanical obstruction of the bowel is complex, primarily associated with the surgical stress response, and also with activated reflex arcs of sympathetic activity to surgical injury and postoperative pain.[4] The stress response initiates a cascade of acute physiological, metabolic and inflammatory events that start with the initiation of general anaesthesia and last 3 to 4 days postoperatively, depending on the type of the anaesthetic and postoperative analgesia techniques.[5,6]

TEA can enhance bowel motility by producing a sympathectomy that leaves the parasympathetic innervation of the gut unopposed, and also by providing pain relief, thus diminishing the systemic stress response.[7,8,9,10,11,12]

Postoperative analgesia with IV morphine has a negative effect on bowel propulsion, through activation of the peripheral μ-receptors of the gut.[13] Further, TEA with opioids versus combination of opioids and local anaesthetics (LAs) has conflicting effects on the activation of the sympathetic response.[14] The positive effect of TEA on gut motility becomes clearer by a multimodal standardised recovery programme[1,11,13,15] and extending TEA for longer than 2 days.[7,9]

Most studies of gastrointestinal dysfunction use clinical indicators to assess POI. However, clinical indicators such as the time to first flatus or stools, correlate poorly with the recovery of the GI function, as they may mirror rectal emptying.[16,17] More objective measures of GI function are the OCTT measured by lactulose H2-breath test, a non-invasive method based on the metabolic release of H2 in the human colon and the CTT of radiopaque markers determined by abdominal X-rays at specified times.[18,19]

The present prospective randomised controlled study tested the hypothesis that postoperative thoracic epidural analgesia with ropivacaine or a combination of ropivacaine and morphine accelerates postoperative GI function and shortens the duration of POI following major thoracic surgery compared to IV morphine. The primary outcome measures used were the OCTT, the CTT and the presence of bowel sounds, flatus and stools, while a secondary outcome measure was the visual analogue (VAS) pain score.

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