Efficacy and Safety of Epidural Analgesia in Patients Undergoing Laparoscopic Abdominal Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND

Epidural analgesia is the gold standard for postoperative pain therapy following laparotomies. However, its appropriateness for pain management after laparoscopic abdominal surgeries remains uncertain.

METHODS

This systematic review with meta-analysis of randomized controlled trials (RCTs) was conducted according to the guidelines of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement; the quality of evidence was assessed with Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Included were trials with adults undergoing laparoscopic abdominal surgery where epidural analgesia was compared to other approaches. Primary outcomes were pain intensity at rest and during movement 24 hours after surgery and the number of patients with any adverse events related to epidural analgesia.

RESULTS

Of 738 screened publications, a total of 41 studies were included in qualitative analysis, 34 studies in quantitative analysis. Fifteen studies compared epidural analgesia with patient-controlled intravenous analgesia (PCIA) with opioids, 10 epidural analgesia with non-patient-controlled opioids, and three epidural analgesia with epidural saline (placebo). Twenty-four hours after surgery epidural analgesia compared to PCIA may slightly reduce pain intensity at rest (n = 10; mean difference [MD]: -0.86 points; 95% confidence interval [CI]: -1.27 to -0.45; 95% prediction interval: -2.06 to 0.34; low-certainty evidence) and may reduce pain during movement even clinically relevant (n = 5; MD: -1.49 points; 95% CI: -2.11 to -0.87; low-certainty evidence). Nonetheless, there are concerns about frequent hypotension due to epidural analgesia (n = 5; relative risk [RR]: 10.1; 95% CI: 2.74-36.6; moderate-certainty evidence) while the impact due to pruritus (n = 4; RR: 0.97; 95% CI: 0.09-10.4; very low-certainty evidence) remains uncertain. Evidence for other comparisons remains limited due to sparse data.

CONCLUSIONS

Preliminary evidence indicates that epidural analgesia has the potential to slightly reduce early postoperative pain intensity after laparoscopic abdominal surgery compared to PCIA. However, its use may be associated with a frequent incidence of hypotension.