Benefits of Thoracic Epidural Analgesia in Patients Undergoing an Open Posterior Component Separation for Abdominal Herniorrhaphy

An open posterior component separation (PCS) is a commonly utilized surgical approach for repair of complex abdominal wall defects and hernias. Although this approach may improve surgical outcomes, significant postoperative pain can be expected given the required laparotomy and extensive abdominal wall manipulation. Both systemic opioids and thoracic epidural analgesia (TEA) are viable postoperative analgesic options, and both are commonly utilized. Although the benefits of TEA have been investigated following a variety of surgeries, there is a paucity of literature related to its efficacy for this particular surgery. The aim of this study was to evaluate the benefits of TEA following open PCS under the hypothesis that the incorporation of TEA into the postoperative analgesic regimen would hasten bowel recovery. Patients who previously underwent an open PCS were identified through an electronic medical record query. A retrospective chart review was then performed, and patients who had TEA, either alone or combined with systemic opioids, were compared with patients who had only systemic opioids. The primary end point was a comparison of the postoperative day (POD) on which a full diet was started. Secondarily, time to liquid diet, postsurgical length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and the rates of several postoperative adverse events were compared. A post hoc analysis was also performed, using the same end points, to compare the subgroup of TEA patients who avoided systemic opioids with all patients who received systemic opioids, whether alone or combined with TEA. One hundred and one patients were ultimately included for analysis. Time to full diet was not significantly different between patients who had TEA, either with or without systemic opioids, and those who received only systemic opioids (TEA 2.6 ± 1.7 vs. systemic opioids 3.1 ± 2.1 [mean POD ± SD], P = .21). Additionally, no statistically significant differences were found for any secondary outcome. In the post hoc analysis, the subgroup of TEA patients who avoided systemic opioids had a significantly faster time to bowel recovery when compared with all patients who received systemic opioids (2.2 ± 1.0 vs. 3.2 ± 2.2, P = .0033). This subgroup also had a significantly shorter time to liquid diet and a decreased postoperative LOS. In conclusion, for patients undergoing an open PCS, the inclusion of TEA in the postoperative analgesic regimen did not by itself hasten the return of bowel function. However, when TEA was utilized and systemic opioids were avoided, bowel recovery occurred significantly sooner and resulted in a shortened hospital LOS.