Pain management after minimally invasive gastrectomy: do we need epidural analgesia?

Epidural analgesia (EDA) has been the gold standard postoperative pain management in gastric cancer surgery for many years. As minimally invasive techniques have reduced surgical trauma, the necessity of EDA is being questioned. This study aimed to evaluate if minimally invasive gastrectomy without EDA was associated with shorter hospital stay and fewer complications compared to operations with EDA.

All patients undergoing minimally invasive gastrectomy for cancer at Karolinska University Hospital (Jan 2015-Aug 2023) were included and divided into groups operated with and without EDA. Data were collected prospectively in an institutional database and retrospectively from medical records. The primary outcome was the length of hospital stay.

Among 211 patients, 43 (20.4 %) had EDA, and 168 (79.6 %) did not, with 12 (7 %) of the latter requiring EDA postoperatively. The median hospital stay was one day longer in group with EDA (median days 7 vs 6 p < 0.001), supported by multivariable adjusted analysis with a coefficient of -1.76 days (95 % CI: -9.01, -2.26 p = 0.003). Patients with EDA had lower pain scores (NRS 0-24h, 0 vs 2 p < 0.001) but required longer postoperative norepinephrine infusion (11.5h vs 0h p < 0.001) and one day longer stay in the high-dependency care unit (p < 0.001). Overall (55.8 % vs 39.9 %, p = 0.060) and severe surgical complications (20.9 % vs 9.5 %, p = 0.039) were more common in the EDA group.

Minimally invasive gastrectomy without EDA can be associated with improved outcomes including shorter hospital stays, fewer postoperative complications, reduced postoperative norepinephrine use, and decreased high-dependency care duration.