title: A comparison of thoracic and lumbar epidural techniques for post-thoracoabdominal esophagectomy analgesia.
abstract: OBJECTIVE
  To compare thoracic epidural analgesia (TEA) using a bupivacaine/fentanyl mixture and lumbar epidural analgesia (LEA) with morphine, in respect to the time to extubation and the quality of post-operative analgesia, in patients having thoracoabdominal esophagectomy.
  
  
  METHODS
  Twenty two patients scheduled for elective thoracoabdominal esophagectomy were randomized to TEA or LEA. Postoperatively, the TEA group received Patient Controlled Epidural Analgesia (PCEA) with bupivacaine 0.125% and 5 microg x ml(BI) fentanyl, and the LEA group received PCEA with 0.2 microg x ml(BI) morphine. A blinded observer assessed criteria for tracheal extubation and the time of tracheal extubation was recorded. Early extubation was defined as tracheal extubation within four hours postoperatively. Visual analogue pain scores at rest (Static Visual Analogue Pain Scores, SVAPS) and with movement (Dynamic Visual Analogue Pain Scores, DVAPS) were recorded at 1, 6, 12, 18 and 24 hr post-extubation. Failure of the epidural protocol (FEP) was defined as a request for additional analgesia.
  
  
  RESULTS
  Tracheal extubation was achieved in 70% of the LEA and 100% of the TEA at four hours postoperatively (P=NS). However, the TEA group achieved earlier extubation times when assessed with log rank testing (P = 0.01). By six hours post-extubation FEP had occurred in 50% of the LEA group but in none of the TEA group (P = 0.01). Mean SVAPS and DVAPS were lower in the TEA than in the LEA group at all measured times (P < 0.01).
  
  
  CONCLUSIONS
  This study has demonstrated superior pain control in patients undergoing thoraco-abdominal esophagectomy treated with TEA than with LEA, particularly for pain with movement. Tracheal extubation occurred earlier in the TEA group, but this difference was not significant at four hours postoperatively.
authors.affiliation: Department of Anesthesia, St. Joseph's Hospital, Hamilton, Ontario, Canada. larrykahn@hotmail.com
authors.forename: L
authors.initials: L
authors.lastname: Kahn
authors.forename: F J
authors.initials: FJ
authors.lastname: Baxter
authors.forename: A
authors.initials: A
authors.lastname: Dauphin
authors.forename: C
authors.initials: C
authors.lastname: Goldsmith
authors.forename: P A
authors.initials: PA
authors.lastname: Jackson
authors.forename: J
authors.initials: J
authors.lastname: McChesney
authors.forename: J D
authors.initials: JD
authors.lastname: Miller
authors.forename: H L
authors.initials: HL
authors.lastname: Takeuchi
authors.forename: J E
authors.initials: JE
authors.lastname: Young
mesh_terms: D000328:Adult; D000368:Aged; D015360:Analgesia, Epidural / Q000379:methods*; D016058:Analgesia, Patient-Controlled; D016629:Esophagectomy; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D008161:Lumbosacral Region; D008297:Male; D008875:Middle Aged; D010149:Postoperative Pain / Q000188:drug therapy*; D013904:Thoracic Vertebrae