Patient-controlled analgesia with continuous perioperative lidocaine and s-ketamine is non-inferior to epidural analgesia after robot-assisted pancreaticoduodenectomy

Background: Postoperative pain is a common complication after surgical intervention, with an incidence up to 88%.1 Severe postoperative pain, numeric rating scale (NRS) >5, has an occurrence of up to 28.5%.2,3 Adequate postoperative analgesia is paramount in order to achieve timely postoperative recovery following abdominal surgery, including pancreaticoduodenectomy. With development of minimally invasive surgical techniques, like robot-assisted pancreaticoduodenectomy, a re-evaluation of the efficacy of existing analgesia techniques is required. We compared epidural analgesia (EDA) to intravenous patient controlled analgesia (PCA) combined with lidocaine/s-ketamine infusion, in order to further establish a superior analgesia technique for robot-assisted pancreaticoduodenectomy. Methods: This single centre retrospective study was approved by the ethics committee and conducted in a peripheral hospital in Rotterdam, the Netherlands. 23 Subjects undergoing robot-assisted pancreaticoduodenectomy were included. Postoperative analgesia was attained through epidural analgesia (EDA) (n=7) or Patient-controlled analgesia (PCA) combined with perioperative continuous intravenous lidocaine/s-ketamine infusion (n=16). Parameters were collected on each postoperative day (D0: day of surgery). Results: Baseline characteristics between groups were comparable. There is no difference in mean postoperative pain between EDA (2 [1;3]) and PCA (1 [1;2]), (figure 1). Additionally, there is no difference in NRS per postoperative day. There is no difference in cumulative use of paracetamol in grams (EDA 17.4 ± 2.8, PCA 16 ± 6.1) or morphine equivalent in milligrams (EDA 13.5 [0; 80], PCA 0 [0; 22]). There is an increased chance of hypotension in the EDA group (29%) when compared to the PCA group (0%). Conclusions: This study demonstrates PCA in combination with lidocaine/s-ketamine infusion provides comparable analgesia to EDA in patients undergoing robot-assisted pancreaticoduodenectomy. Given the potential complications associated with EDA (e.g. hypotension), PCA with lidocaine/s-ketamine infusion is now our preferred analgesia modality for these procedures, permitting fast track recovery.