Randomized Clinical Trial
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 21, 2015; 21(43): 12448-12456
Published online Nov 21, 2015. doi: 10.3748/wjg.v21.i43.12448
Epidural anesthesia improves pancreatic perfusion and decreases the severity of acute pancreatitis
Samira M Sadowski, Axel Andres, Philippe Morel, Eduardo Schiffer, Jean-Louis Frossard, Alexandra Platon, Pierre-Alexandre Poletti, Leo Bühler
Samira M Sadowski, Axel Andres, Philippe Morel, Leo Bühler, Department of Visceral and Transplantation Surgery, University Hospitals of Geneva, 1211 Geneva 14, Switzerland
Eduardo Schiffer, Department of Anesthesiology, University Hospital Geneva, 1211 Geneva 14, Switzerland
Jean-Louis Frossard, Department of Gastroenterology, University Hospital Geneva, 1211 Geneva 14, Switzerland
Alexandra Platon, Pierre-Alexandre Poletti, Department of Radiology, University Hospital Geneva, 1211 Geneva 14, Switzerland
Author contributions: Bühler L, Morel P, Poletti PA, Schiffer E and Frossard JL designed the research; Sadowski SM, Andres A, Schiffer E, Platon A and Poletti PA performed the research; Sadowski SM, Andres A, Schiffer E, Platon A, Poletti PA and Frossard JL analyzed the data; Sadowski SM, Bühler L, Platon A and Poletti PA wrote the paper.
Supported by a research grant of the University Hospitals of Geneva (to Bühler L).
Institutional review board statement: The Ethics Board of Geneva’s University Hospital approved the study in 2004 (HUG 02-0555).
Clinical trial registration statement: This study is registered at http://www.clinicaltrials.gov. The registration identification number is NCT01607996.
Informed consent statement: All study participants provided informed written consent prior to study enrollment.
Conflict-of-interest statement: This study was funded by a research grant from the University Hospitals of Geneva to Bühler Leo. JL Frossard received payment from the University Hospitals of Geneva for lectures. The other authors have nothing to disclose.
Data sharing statement: Consent was not obtained, but the presented data are anonymized and the risk of identification is low.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Leo Bühler, Professor, Department of Visceral and Transplantation Surgery, University Hospitals of Geneva, Rue Gabrielle Perret-Gentil 4, 1211 Geneva 14. Switzerland. leo.buhler@hcuge.ch
Telephone: +41-22-3727698 Fax: +41-22-3727689
Received: May 2, 2015
Peer-review started: May 8, 2015
First decision: June 2, 2015
Revised: June 19, 2015
Accepted: September 14, 2015
Article in press: September 15, 2015
Published online: November 21, 2015
Abstract

AIM: To study the safety of epidural anesthesia (EA), its effect on pancreatic perfusion and the outcome of patients with acute pancreatitis (AP).

METHODS: From 2005 to August 2010, patients with predicted severe AP [Ranson score ≥ 2, C-reactive protein > 100 or necrosis on computed tomography (CT)] were prospectively randomized to either a group receiving EA or a control group treated by patient controlled intravenous analgesia. Pain management was evaluated in the two groups every eight hours using the visual analog pain scale (VAS). Parameters for clinical severity such as length of hospital stay, use of antibiotics, admission to the intensive care unit, radiological/clinical complications and the need for surgical necrosectomy including biochemical data were recorded. A CT scan using a perfusion protocol was performed on admission and at 72 h to evaluate pancreatic blood flow. A significant variation in blood flow was defined as a 20% difference in pancreatic perfusion between admission and 72 h and was measured in the head, body and tail of the pancreas.

RESULTS: We enrolled 35 patients. Thirteen were randomized to the EA group and 22 to the control group. There were no differences in demographic characteristics between the two groups. The Balthazar radiological severity score on admission was higher in the EA group than in the control group (mean score 4.15 ± 2.54 vs 3.38 ± 1.75, respectively, P = 0.347) and the median Ranson scores were 3.4 and 2.7 respectively (P = NS). The median duration of EA was 5.7 d, and no complications of the epidural procedure were reported. An improvement in perfusion of the pancreas was observed in 13/30 (43%) of measurements in the EA group vs 2/27 (7%) in the control group (P = 0.0025). Necrosectomy was performed in 1/13 patients in the EA group vs 4/22 patients in the control group (P = 0.63). The VAS improved during the first ten days in the EA group compared to the control group (0.2 vs 2.33, P = 0.034 at 10 d). Length of stay and mortality were not statistically different between the 2 groups (26 d vs 30 d, P = 0.65, and 0% for both respectively).

CONCLUSION: Our study demonstrates that EA increases arterial perfusion of the pancreas and improves the clinical outcome of patients with AP.

Keywords: Severe acute pancreatitis, Epidural anesthesia, Pancreatic necrosectomy, Pancreatic perfusion, Computed tomography

Core tip: We conducted this prospective randomized study to explore the safety of epidural anesthesia (EA), its effect on pancreatic perfusion and the outcome of patients with acute pancreatitis, as high mortality is linked with necrosis of the gland. We found an improvement in perfusion of the pancreas in the EA group. Necrosectomy was performed in 1/13 patients in the EA group vs 4/22 patients in the control group.