THORACIC VERSUS LUMBAR EPIDURAL ANESTHESIAS EFFECT ON PAIN CONTROL AND ILEUS RESOLUTION AFTER RESTORATIVE PROCTOCOLECTOMY

Background. Epidural anesthesia as a perioperative adjunct has been sh own to provide superior pain control and has been implicated in more r apid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. Methods. One hun dred seventy-nine patients (120 male, 59 female; average age, 36 years ) underwent restorative proctocolectomy for ulcerative colitis or fami lial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10 ) epidurals. Group LUM (n = 51) received lumbar (L2 to L4 epidurals, a nd group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative ri sk factors, postoperative pain and ileus resolution. Results. Epidural narcotics, alone or combined with local anesthetics, were administere d for an average of 2 (LUM) to 4 (THO) days without significant compli cations. infrequent problems related to the epidural catheters include d self-limited headaches or back pain (four) and site infections (two) . Epidural failure, as measured by conversion to PCA for inadequate pa in control, was nor significantly greater for LUM (25 %) than THO (23 %). Average pain scores, rated daily on a visual analog scale, were si gnificantly higher (indicating more pain) for PCA patients (4.2) durin g postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution as determined by stool output and return of bowel sounds, was significantly faster in THO than in LU M or PCA (p < 0.05). Resolution of ileus was not significantly differe nt between PCA and LUM (p > 0.5). Conclusions. Thoracic epidural analg esia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postop erative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also e conomically justifiable and may prove to impact significantly on futur e postoperative management by reducing length of hospitalization Our d ata and those of others are most striking in these regards for patient s with thoracic catheters, indicating the importance of vertebral leve l in epidural drug administration.