P-P18 Thoracic epidural VS intrapleural analgesia for pancreaticoduodenectomy – a study on analgesic and non-analgesic outcomes

Background Thoracic epidural analgesia (TEA) has been the traditional option for post-operative pain management for Kausch-Whipple pancreaticoduodenectomy (KWPD) via a ‘reverse L’ incision. An alternative option with inter-pleural analgesia (IPA) has become popular. However, the superior form of analgesia for KWPD regarding analgesic and non-analgesic outcomes is unclear. This study aims to establish if IPA is equivalent to TEA. Methods Retrospective study of all patients who underwent KWPD with ‘reverse L’ incision by a single surgeon between February 2014 to June 2016. All received either IPA or TEA post-operatively; patients who had rectus sheath catheter and spinal anaesthesia were excluded. To reduce bias, the Anaesthetist, rather than Surgeon, decided the choice of analgesia based on personal skill. Efficacy regarding analgesia were collected by nursing staff as patient-reported pain severity (mild, moderate or severe). Data were collected from patient case notes and electronic records. This study analysed analgesia efficacy, complications, inotrope use, and intensive treatment unit (ITU) stay. Results A total of 40 included in the study. Twenty-two patients had TEA (45% female, median age 68 years) and 18 had IPA (44% female, median age 67 years). Median Charleson Comorbidity Index (CCI) was 5 for both. Patient-reported pain was not statistically different (p = 0.15). We noted more analgesia complications with TEA (not working=4, leakage=2, haemodynamic instability=1, lower limb anaesthesia=1) than IPA (leakage=1; p = 0.027). Eleven (50%) TEA and eight (44%) IPA patients required inotropes. TEA patients required significantly longer duration (median duration 35 VS 18 hours, p = 0.047). Median ITU stay was 3 and 2 days for TEA and IPA patients, respectively. Conclusions Both TEA and IPA provide adequate pain relief for KWPD performed via a ‘reversed L’ incision. However, evidence suggests TEA was associated with significantly more analgesia-related complications and longer inotropic requirements. Furthermore, there was also a trend towards ITU stays with TEA. Therefore, we would recommend the use of inter-pleural analgesia over thoracic epidural.

Intrapleural analgesia after endoscopic thoracic sympathectomy

PURPOSE: To compare analgesia traditionally used for thoracic sympathectomy to intrapleural ropivacaine injection in two different doses. METHODS: Twenty-four patients were divided into three similar groups, and all of them received intravenous dipyrone. Group A received intravenous tramadol and intrapleural injection of saline solution. Group B received intrapleural injection of 0.33% ropivacaine, and Group C 0.5% ropivacaine. The following aspects were analyzed: inspiratory capacity, respiratory rate and pain. Pain was evaluated in the immediate postoperative period by means of the visual analog scale and over a one-week period. RESULTS: In Groups A and B, reduced inspiratory capacity was observed in the postoperative period. In the first postoperative 12 hours, only 12.5% of the patients in Groups B and C showed intense pain as compared to 25% in Group A. In the subsequent week, only one patient in Group A showed mild pain while the remainder reported intense pain. In Group B, half of the patients showed intense pain, and in Group C, only one presented intense pain. CONCLUSION: Intrapleural analgesia with ropivacaine resulted in less pain in the late postoperative period with better analgesic outcomes in higher doses, providing a better ventilatory pattern.