Effect of epidural analgesia on bowel function in laparoscopic colorectal surgery: a systematic review and meta-analysis.

PURPOSE: Use of thoracic epidural analgesia (TEA) with local anesthetic and adjuncts, such as opioids, are cornerstones of ERAS (Enhanced Recovery After Surgery) and are considered to play a key role in recovery after colorectal surgery. However, its effect on bowel function may lead to prolong hospital stay and is still a matter of debate. The purpose of this systemic review was to assess whether epidural analgesia could have a detrimental effect on bowel function in laparoscopic colorectal surgery with a subsequent effect on hospital stay duration, leading to failure of ERAS in colorectal surgery. METHODS: A systematic review of randomized, controlled trials for the effect of epidural analgesia on laparoscopic colorectal surgery was performed. The effect on postoperative recovery was evaluated in terms of return of bowel function as the primary outcome, whereas length of stay (LOS), pain score on visual analogue scale, operative time, and incidence of postoperative complications and side-effects of analgesia were recorded as secondary outcomes. RESULTS: Six trials published between 1999 and 2011 were included in the final analysis. TEA significantly improves return of bowel function assessed by time to first bowel motion [WMD -0.62 (-1.11, -0.12) with Z = 2.43; P = 0.02, 95 % confidence interval (CI)], and pain scores [WMD -1.23 (-2.4, -0.07)] with Z = 2.07; P = 0.04, 95 % CI]. TEA did not influence duration of hospital stay [WMD -0.47 (-1.55, 0.61)] with Z = 0.85 (P = 0.39, 95 % CI). No significant increase in operative time or side effects was associated with TEA. CONCLUSIONS: Despite of some beneficial effect of epidural analgesia on return of bowel function and pain in laparoscopic surgery, it does not affect LOS, which is multifactorial.

Incidence of right-sided colonic tumors (non-appendiceal) in patient's ≥40 years of age presenting with features of acute appendicitis.

INTRODUCTION: Non-appendiceal tumors can mimic and present with clinical features of acute appendicitis in patients of age 40 years or above. The aim of this prospective study is to investigate the incidence of right-sided (non-appendiceal) colonic tumors in patients presenting with clinical features of acute appendicitis. METHODS: A prospective data analysis of 1662 patients using appendectomy database was performed from 2005 to 2011. Patients above age 40 years or older were included. Patients were compared for demographic data, clinical presentation, radiological findings, operative technique & findings, histo-pathological findings and postoperative complications. The primary outcome was incidence of right-sided colonic (non-appendiceal) tumors presenting with features of acute appendicitis. Secondary outcomes measured were, role of diagnostic radiology, negative appendectomy rate, length of stay and changing trends in operative techniques. RESULTS: From 1662 patients initially reviewed, only 179 patients (10.77%) age 40 years or above mean (56 ± 11.75), median 54 (40-89), with clinical features of acute appendicitis were included in the final analysis. F:M ratio was (1:1.06). CT scan showed in only 1 patient (1.25%, OR = 0.806, p = 0.695), suspicion of cecal tumor and underwent right hemicolectomy. Histological examination of specimen showed, 2 patients (1.11%, OR = 1.10, p = 0.47) had primary appendiceal tumors, in which one patient was histologically reported as appendiceal mucocele (mucinous cystadenoma with low-grade dysplasia), while the other one had appendeceal carcinoid (Goblet cell carcinoid). In the other tumor group one patient had metastatic involvement of appendix from ovarian tumor. The time to appendectomy in radiological group was delayed by (9.2 ± 3.7 h). 131 (73.1%) had laparoscopic while 48 (26.81%) underwent open appendectomy. The negative appendectomy rate was (1.12%) and 30 days complication rate was (11.73%, p = 0.27). Mean length of stay was 3.54 ± 2.1 days. CONCLUSION: Right-sided colonic (cecal) tumors rarely present with features of acute appendicitis. Only those patients with atypical presentation and findings should have pre-operative radiological evaluation.