Meta-analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

Background The optimal analgesic technique after pancreatoduodenectomy remains under debate. This study aimed to see whether epidural analgesia (EA) has superior clinical outcomes compared with non-epidural alternatives (N-EA) in patients undergoing pancreatoduodenectomy. Methods A systematic review with meta-analysis was performed according to PRISMA guidelines. On 28 August 2018, relevant literature databases were searched. Primary outcomes were pain scores. Secondary outcomes were treatment failure of initial analgesia, complications, duration of hospital stay and mortality. Results Three RCTs and eight cohort studies (25 089 patients) were included. N-EA treatments studied were: intravenous morphine, continuous wound infiltration, bilateral paravertebral thoracic catheters and intrathecal morphine. Patients receiving EA had a marginally lower pain score on days 0-3 after surgery than those receiving intravenous morphine (mean difference (MD) -0 center dot 50, 95 per cent c.i. -0 center dot 80 to -0 center dot 21; P < 0 center dot 001) and similar pain scores to patients who had continuous wound infiltration. Treatment failure occurred in 28 center dot 5 per cent of patients receiving EA, mainly for haemodynamic instability or inadequate pain control. EA was associated with fewer complications (odds ratio (OR) 0 center dot 69, 95 per cent c.i. 0 center dot 06 to 0 center dot 79; P < 0 center dot 001), shorter duration of hospital stay (MD -2 center dot 69 (95 per cent c.i. -2 center dot 76 to -2 center dot 62) days; P < 0 center dot 001) and lower mortality (OR 0 center dot 69, 0 center dot 51 to 0 93; P = 0 center dot 02) compared with intravenous morphine. Conclusion EA provides marginally lower pain scores in the first postoperative days than intravenous morphine, and appears to be associated with fewer complications, shorter duration of hospital stay and less mortality.