No Need to Add Epidural to General Anesthesia for Cystectomy

By Marilynn Larkin

February 04, 2020

NEW YORK (Reuters Health) - Compared to cystectomy patients who had general anesthesia alone, those who received general plus epidural anesthesia had more complications and no advantages with regard to postoperative stay, reoperation or readmission rates, an observational study shows.

Epidural anesthesia has been used as part of the Enhanced Recovery After Surgery (ERAS) process across multiple US institutions to decrease post-operative narcotic use and improve various parameters of care, Dr. Laura Bukavina of Case Western Reserve University School of Medicine in Cleveland told Reuters Health by email.

The ERAS program "is focused on improving surgical outcomes and enhancing patient experiences before, during and after surgery," she said. "Typically, a multidisciplinary team of surgeons, anesthesiologists, nurses, advance practice providers and others work in collaboration to implement highly effective, evidence-based interventions that accelerate recovery and improve outcomes."

However, "Unlike many parts of the ERAS protocol that have been evaluated in either retrospective or prospective manner, use of adjunct anesthesia, such as an epidural, has not been evaluated to see if it in fact improved patient-centered outcomes."

"This study did just that," she continued. "As compared to patients who did not receive epidural analgesia, there was no difference in readmission rate or reoperation. In fact, (with) epidural analgesia, an average patient stayed in the hospital longer - we suspect due to having limited mobility with the epidural catheters in place - and had a higher risk of any complication."

"We believe this is practice changing," she added. "From the feedback we received, many surgeons have suspected as much, and have started to shy away from epidural analgesia. This (study) provides evidence and validation to evaluate alternative means for improved analgesia in cystectomy patients."

The researchers used data from the National Surgical Quality Inpatient Program on U.S. patients who underwent a cystectomy with ileal conduit between 2014 and 2017. Patients were subdivided based on anesthesia modality. Baseline differences between subgroups - e.g., smoking, prevalence of hypertension - were adjusted with propensity score-matching.

As reported in Urology, 2,956 patients were included. The mean age was 70.4; 80.8% were men; and 56.1%, white. As Dr. Bukavina noted, analyses showed no differences between the general anesthesia alone and adjuvant epidural groups in terms of operative time (mean, 307.29 minutes), proportion of patients needing transfusion (30.1% vs. 33.7%), reoperations (5.2% vs. 4.9%), and procedure-related readmissions (18.1% vs. 21.1%).

Compared to general anesthesia, adjuvant epidural anesthesia was associated with increased odds of procedure-related complications (adjusted OR, 1.264) and an increased trend for development of pulmonary emboli (1.8% vs. 0.5%).

Dr. David Y.T. Chen, Director, Urologic Oncology Fellowship Program, Professor of Surgical Oncology at Fox Chase Cancer Center in Philadelphia, commented in an email to Reuters Health, "The...most prominent problem with this analysis is there is not a clear explanation to what selection bias might exist in a patient being recommended for combined anesthesia."

"Current common practice suggests that general anesthesia alone provides sufficient perioperative analgesia with this operation, whereas adjuvant epidural anesthesia is typically unneeded," he said. "This use of general anesthesia alone has further extended to the application of minimally invasive surgery with radical cystectomy, where post-operative pain is typically less significant compared to traditional open surgery."

"My concern," he noted, "is that patients who were selected to have combination general and adjuvant epidural anesthesia may have more complicated medical or surgical parameters, or might have a clinically higher stage cancer, where the surgeon estimated the radical cystectomy operation might be more difficult or possibly require longer operative time than average and the additional adjuvant epidural anesthesia was applied."

"So, while combination anesthesia may be correlated to higher complications, it might simply serve as a marker of higher risk patients," he said.

Nonetheless, he added, regardless of whether the study findings are correct, "there is no clear benefit to applying combination therapy for the average patient."

SOURCE: Urology, online January 15, 2020.