A randomized clinical trial to compare the efficacy of continuous local anesthetic wound infusion with thoracic epidural analgesia in post-operative pain control after pancreatic surgery

Introduction: Few data support the use of thoracic epidural analgesia (TEA) in pancreatic surgery.Recent evidence suggested that the use of continuous wound local anesthetic infusion (CWI) could be areliable and effective procedure in different types of surgeries. The aim of this study was to determine ifCWI could be an alternative to TEA in pancreatic surgery.Methodology: Eighty consecutive patients that received a subcostal incision for pancreatic resectionfrom April 2012 to February 2013 in our institute were randomized into two groups to receive eitherpostoperative TEA or CWI. Patients with contraindications to epidural analgesia or any drugs in theprotocol, not able to comply with the protocol or use a PCA device were excluded.Rescue analgesia was provided to all patients via patient-controlled analgesia (PCA) which deliveredboluses of morphine. Postoperative pain levels where considered as primary end point, and evaluatedwith Verbal Numeric Scale (VNS). As secondary end points, we studied consumption of morphine,postoperative complications, length of stay, resumption of complete bowel function, and time tomobilization. Circulating cytokines and chemokines were evaluated in 20 patients to assess the effects onthe inflammatory response.Results: None of the two techniques demonstrated advantages in terms of static and dynamic postoperativepain control (VNS). Median morphine consumption was not significantly different in TEA [12 mg (IQR9-23)] and in CWI group [15 mg (IQR 10-29)] (p = 0.527). There was no significant difference betweenthe two groups with regards to secondary endpoints. The median length of stay was comparable in CWIand TEA group [10 (IQR 9-16) vs 12 (IQR 8-15,5)] days; (p = 0.481). Similar levels of inflammatorymediators were found. In the TEA group 13% of the patients experienced hypotension; no such caseswhere observed in CWI group.Conclusions: Our study failed to demonstrate a superiority of TEA compared to CWI in management ofpostoperative pain after pancreatic surgery.