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Original Investigation |

Epidural Analgesia in Laparoscopic Colorectal Surgery:  A Nationwide Analysis of Use and Outcomes

Wissam J. Halabi, MD1; Celeste Y. Kang, MD1; Vinh Q. Nguyen, PhD2; Joseph C. Carmichael, MD1; Steven Mills, MD1; Michael J. Stamos, MD1; Alessio Pigazzi, MD, PhD1
[+] Author Affiliations
1Department of Surgery, Irvine School of Medicine, University of California, Irvine
2Department of Statistics, University of California, Irvine
JAMA Surg. 2014;149(2):130-136. doi:10.1001/jamasurg.2013.3186.
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Importance  The use of epidural analgesia in laparoscopic colorectal surgery has demonstrated superiority over conventional analgesia in controlling pain. Controversy exists, however, regarding its cost-effectiveness and its effect on postoperative outcomes.

Objectives  To examine the use of epidural analgesia in laparoscopic colorectal surgery at the national level and to compare its outcomes with those of conventional analgesia.

Design, Setting, and Participants  This is a retrospective review of laparoscopic colorectal cases performed with or without epidural analgesia for cancer, diverticular disease, and benign polyps. Patient demographic characteristics, disease and procedure types, and hospital settings were listed for patients in the epidural and conventional analgesia groups. A 1 to 4 case-matched analysis was performed, matching for patient demographic characteristics, hospital setting, indications, and procedure type. Data were obtained from the Nationwide Inpatient Sample between January 1, 2002, and December 31, 2010.

Main Outcomes and Measures  Total hospital charge, length of stay, mortality, pneumonia, respiratory failure, urinary tract infection, urinary retention, anastomotic leak, and postoperative ileus.

Results  A total of 191 576 laparoscopic colorectal cases were identified during the study period. Epidural analgesia was used in 4102 cases (2.14%). Epidurals were more likely to be used in large teaching hospitals, cancer cases, and rectal operations. On case-matched analysis, epidural analgesia was associated with a longer hospital stay by 0.60 day (P = .003), higher hospital charges by $3732.71 (P = .02), and higher rate of urinary tract infection (odds ratio = 1.81; P = .05). Epidural analgesia did not affect the incidence of respiratory failure, pneumonia, anastomotic leak, ileus, or urinary retention.

Conclusions and Relevance  The perioperative use of epidural analgesia in laparoscopic colorectal surgery is limited in the United States. While epidural analgesia appears to be safe, it comes with higher hospital charges, longer hospital stay, and a higher incidence of urinary tract infections.

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Can the Database Answer the Question?
Posted on December 16, 2013
Kenneth C. Cummings III, MD, MS; Aiswarya Chandran Pillai MD, MS; Siran Koroukian, PhD
Anesthesiology Institute, Cleveland Clinic
Conflict of Interest: None Declared
We read with great interest the recent article by Halabi, et al(1) investigating the relationship between epidural analgesia and outcomes in laparoscopic colorectal surgery. The authors are to be commended for approaching this question by using a large national database. We believe, however, that there is at least one major issue which may challenge the validity of their analysis.The Nationwide Inpatient Sample (NIS) is a valuable tool to investigate questions at the population level (2). In this case, however, we believe the NIS lacks sufficient granularity to correctly identify patients who received epidural anesthesia/analgesia. In particular, the NIS only uses International Classification of Diseases, 9th Edition (Clinical Modification) codes to identify epidural use. Specifically, the authors use codes 03.90 (Insertion Of Catheter Into Spinal Canal For Infusion Of Therapeutic Or Palliative Substances) and 03.91 (Injection Of Anesthetic Into Spinal Canal For Analgesia), neither of which is specific to epidural analgesia. Anesthesiologist billing for epidural catheter placement commonly uses Common Procedural Terminology (CPT) codes 62318 (cervical or thoracic) or 62319 (lumbar or sacral). Daily management incurs a CPT code of 01996. None of these codes are present in the NIS and likely lead to under-reporting of epidural use. In a preliminary query of the NIS data from 1998 to 2005, we found 162, 406 patients undergoing open gastrectomy or colectomy. Using the available codes in the NIS data, we identified only 6,616 patients with epidural codes (4.1%). This is drastically lower than the rates we have identified using the SEER-Medicare database containing CPT codes. (3)The fact that the authors found epidural use in 2.14% of their cases suggests that either epidural use is vanishingly rare in this population or is significantly under-represented in the database. Making inferences using such a small sample with (likely) a significant degree of misclassification in the absence of clinical data about the epidurals used (location, timing, choice of medication, technique, et cetera) is a setup for erroneous conclusions.References1. Halabi WJ, Kang CY, Nguyen VQ, et al.: Epidural analgesia in laparoscopic colorectal surgery: A nationwide analysis of use and outcomes. JAMA Surgery 2013: -2. Agency for Healthcare Research and Quality: Healthcare Cost and Utilization Project Nationwide Inpatient Sample, 2002-2010. Rockville, MD, Agency for Healthcare Research & Quality, 20123. Cummings KC, 3rd, Xu F, Cummings LC, Cooper GS: A Comparison of Epidural Analgesia and Traditional Pain Management Effects on Survival and Cancer Recurrence after Colectomy: A Population-based Study. Anesthesiology 2012; 116: 797-806
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