World J Surg (2009) 33:1802–1808
DOI 10.1007/s00268-009-0131-2
A Change in Practice from Epidural to Intrathecal Morphine
Analgesia for Hepato-Pancreato-Biliary Surgery
Magdalena Sakowska Æ Elizabeth Docherty Æ
David Linscott Æ Saxon Connor
Published online: 23 June 2009
Ó Société Internationale de Chirurgie 2009
Abstract
Background This study was designed to audit the change
of anesthetic practice from thoracic epidural analgesia
(TEA) to intrathecal morphine (ITM) combined with
patient-controlled analgesia (PCA) for hepato-pancreato-
biliary (HPB) surgery.
Methods All patients who underwent major HPB surgery
and received TEA or ITM from March 2005 to March 2008
were identified. Patients who received PCA alone were
used for comparison. Data were retrospectively collected
and analyzed for success of TEA, perioperative intravenous
fluid (IVF) volume administered, hypotension, complica-
tions, and hospital stay.
Results During the study period, 51 (32%) patients
received TEA, 79 (49%) received ITM plus PCA opiate,
and 31 (19%) received PCA alone. The incidence of
postoperative hypotension was significantly higher in those
who received TEA compared with those who received ITM
(21/51 (41%) vs. 7/79 (9%), P \ 0.001). The median
(range) perioperative IVF administration was higher in the
TEA group compared with the ITM group for both the first
24 h (6 (3–11) liters vs. 5 (3–11) liters, P \ 0.05) and in
total (15.5 (5–48.5) liters vs. 9 (3–70) liters, P \ 0.001).
Respiratory complications occurred in five (10%) of the
TEA group compared with one (1%) in the ITM group
M. Sakowska (&)
S. Connor
Department of Surgery, Christchurch Hospital,
Private Bag 4710, Christchurch, New Zealand
e-mail: magda.sakowska@cdhb.govt.nz
E. Docherty
D. Linscott
Department of Anaesthesia, Christchurch Hospital,
Christchurch, New Zealand
123
(P \ 0.05). The median (range) hospital stay was longer in
the TEA group compared with the ITM group (9 (3–36)
days vs. 7 (3–55) days, P \ 0.01).
Conclusions In a resource-limited setting, ITM, com-
pared with TEA, is associated with a reduced incidence of
postoperative hypotension, reduced IVF requirements,
shorter hospital stay, and lowers the incidence of respira-
tory complication.
Introduction
Evidence from meta-analyses has suggested that TEA pro-
vides superior pain relief to intravenous opioid analgesia for
major abdominal surgery as well as reducing perioperative
mortality and morbidity [1–4]. The MASTER trial [5]
investigated these claims with a randomized, controlled,
design study, which showed no mortality advantage for TEA
compared with patient-controlled analgesia (PCA) in high-
risk patients after major abdominal surgery. However, it did
show a small benefit in the reduction of postoperative
respiratory failure (23% vs. 30%, P = 0.02) and a reduction
in visual analogue scores (VAS) in the TEA group. Thus,
uncertainty remains about the exact role of epidural anal-
gesia for patients who undergo major abdominal surgery.
As clinicians it is important to look for improvements in
perioperative outcomes that could accelerate recovery,
reduce morbidity, and shorten hospital stay [6]. Analgesia
and fluid management are key components of this post-
operative care. TEA has been used widely for major
abdominal surgery; however, its use has been limited by
the need for intensive monitoring with high rates of
medical and nursing intervention, the incidence of hypo-
tension, incomplete analgesia, and high failure rates [7].
Locally, additional factors discouraging TEA use included
World J Surg (2009) 33:1802–1808
anecdotally higher epidural failure rates than that seen
elsewhere [5, 7], the routine treatment of hypotension
predominantly with intravenous fluid challenges, and
restriction on the use of vasopressors outside the intensive
care unit, restricted levels of staffing of the acute pain
service after hours, and occasionally delay in removal of
the epidural catheter because of reduced staffing levels on
weekends. Intense and frequent monitoring also contributes
to substantial sleep deprivation for some patients. The
potential for development of a coagulopathy after liver
resection increased concern about the risk of an epidural
hematoma at the time of epidural catheter removal [8].
For these reasons, and consistent with a recent Aus-
tralasian trend [9], a decision to change to a single dose of
ITM with postoperative PCA was made for patients
undergoing HPB surgery.
ITM has been used for postoperative analgesia since
1979 [10]. Initially doses as high as 0.2 mg/kg were used.
Side effects, including respiratory depression, were com-
mon and resulted in cautionary reports [11, 12]. More
recently smaller doses have been used, commonly
0.1–0.3 mg. These lower doses have been safely used and
reported in multiple trials [13–17]. Locally, favorable
experience with ITM for obstetric and orthopedic surgery
preceded its use for general surgical patients.
The quality of analgesia produced with ITM has been
shown to be superior to PCA morphine alone whilst
simultaneously reducing PCA morphine consumption
[17–21]. ITM produces less sedation and a greater ability to
mobilize than equianalgesic systemic morphine [22]. The
quality of analgesia from ITM is no less than from con-
tinuous epidural analgesia [23]. Favorable comments have
been made regarding the cost of ITM where it replaces
epidural analgesia, but no formal cost analysis studies have
been completed [13, 16].
This study was designed to audit the change in practice
from TEA to ITM, with a particular focus on the incidence
of hypotension, postoperative intravenous fluid use, respi-
ratory depression/complication, and length of inpatient
hospitalization for patients who underwent HPB surgery.
Methods
From a prospective HPB database, all patients who
underwent surgery from March 2005 to March 2008 were
identified. Data were then retrieved retrospectively. The
current study met the definition of an audit and quality
assurance-related activity as per New Zealand national
ethics committee guidelines, therefore, it did not require
specific ethical committee review [24].
Before June 2006, patients who underwent HPB surgery
had an epidural catheter placed preoperatively to provide
1803
perioperative analgesia. For patients in whom there was
failure of TEA or contraindications to epidural catheter
placement, standard intravenous opiate PCA was used
alone. After June 2006, ITM was introduced as first-choice
perioperative analgesia. Patients who declined or had
contraindications to ITM received standard PCA alone.
The standard TEA prescription contained Ropivacaine
0.2% with Fentanyl 2 lg/ml; further changes to the rate of
the infusion or bolus doses were given as clinically
required by the acute pain team and were tailored to
patient’s age and medical conditions. For the purpose of
the audit, the epidural was deemed to have failed if the
patient required intravenous opiates or the epidural catheter
was removed before the third postoperative day.
ITM was administered immediately preoperatively by
lumbar puncture with a 26-g pencil point needle. Doses
(morphine ± fentanyl ± bupivacaine) were left to the
discretion of the individual anesthetist.
PCA prescriptions were made at the preference of
individual anesthetists to optimize individual pain control
postoperatively. Because of concerns regarding respiratory
depression from the combination of ITM and PCA mor-
phine, patients who received ITM had a limit of 5 mg of
morphine per hour, with a 10-min lockout for the first
18–24 h after surgery.
Because of the variability in type of drug administered
via PCA, a surrogate marker to total amount of analgesic
received on PCA is the duration of the PCA. Doses of
intraoperative and postoperative intravenous opiates were
recorded. All patients received regular oral Paracetamol
(1 g 6 hourly), and other postoperative analgesic drugs
used also were recorded. Wound catheters were introduced
in May 2007 as a local anesthetic adjunct.
All patients were given a similar general anesthetic
(endotracheal tube, intermittent positive pressure ventila-
tion, volatile and relaxant) and no significant changes to the
preoperative or postoperative nursing and surgical tech-
niques were noted during the study period. For comparison,
patients who received PCA alone during the two study
periods were compared to identify if any external factors
may have been responsible for any change in outcomes.
Surgical times were taken from induction of general
anesthesia to arrival in the recovery room or the intensive
care unit (ICU).
Perioperative intravenous fluid use was recorded. The
first 24-h intravenous fluid use was taken from the start of
the anesthetic, and total intravenous fluid use was calcu-
lated for the remainder of the admission. Fluid volumes,
including blood products, were rounded to the nearest
500 ml. Total parenteral nutrition volumes, where used,
were excluded.
Specific complications were defined as shown in
Table 1. The incidence of some complications, such as
123
1804 World J Surg (2009) 33:1802–1808

Table 1 Definitions used for specific complications
Complications Definition
Major surgical Anastomotic leak
complication Intra-abdominal fluid collection on
computerized tomography
Bleeding requiring a return to theatre
Pancreatic fistula
Wound infection requiring antibiotics
Respiratory Consolidation on chest X-ray
complication
Clinically diagnosed lower respiratory tract
infection treated with antibiotics
Respiratory Apneic episode
depression
Reduced respiratory rate treated with Naloxone
Hypotension Two recorded systolic blood pressures below
90 mmHg (not necessarily consecutive)
pruritus, postoperative nausea and vomiting, and paralytic
ileus, were not consistently recorded or difficult to measure
retrospectively and, therefore, were not included in the
comparison. All patients were catheterized preoperatively
so the incidence of urinary retention could not be
measured.
Patient data were analyzed on an intention-to-treat basis.
All values recorded are median (range) unless otherwise
stated. Percentages are shown if the denominator is [50.
Nominal variables were compared using v2 test or Fisher’s
exact test as appropriate. Continuous variables were ana-
lyzed by Mann-Whitney U test or Kruskal-Wallis. P value
is considered significant if \0.05.
Results
A total of 171 patients were identified from the HPB
database. Before the introduction of ITM in June 2006, 16
patients had contraindications to TEA and received PCA
alone. After June 2006, 15 had PCA alone and 7 patients
Table 3 Summary doses of drugs used in patients receiving intra-
thecal morphine (ITM)
ITM doses (n = 79) Median Range
Bupivacaine (mg) 1.5 0–15
Fentanyl (lg) 20 0–25
Morphine (lg) 200 20–200
had epidural analgesia, giving 51 (32%) patients in the
TEA group and 31 (19%) patients in the PCA alone group.
Seventy-nine (49%) patients were treated with ITM. Ten
(6%) patients were excluded from the analysis: two
patients had undergone laparoscopy only, four had not
received TEA, ITM, or PCA, and in four patients the notes
could not be retrieved for review. Demographic and
intraoperative factors were comparable between the TEA
and ITM groups (Table 2). ITM drug doses are summa-
rized in Table 3.
In the TEA group, epidural duration was 3 (range, 0–6)
days with 19 (38%) patients experiencing epidural failure.
Thirty patients (59%) required additional analgesia in the
form of postoperative PCA, including two patients whose
epidural had failed. An additional two patients experienced
failed placement of the epidural catheter preoperatively.
Five patients had inadequate epidural analgesia in recovery,
requiring supplemental intravenous opiates. Five of the
failed epidurals were not taken out until the third postop-
erative day but needed to be supplemented with intravenous
opiates. Failed epidural analgesia did not alter the length of
stay (failed epidural: median hospital stay 10 (range, 5–28)
days compared with successful epidural: 9 (range, 4–36)
days; P = 0.69).
Postoperative PCA was used in all patients in the ITM
group for a median duration of 58 (range, 10–142) hours.
This was not different than the median PCA duration of
57 (range, 16–204) hours in the TEA group or the 72.5
(range, 23–254) hours during which PCA was used alone
(P = 0.14).

Table 2 Summary of the

Variable TEA ITM PCA
demographic and intraoperative
parameters in the thoracic n (%) 51 (32) 79 (49) 31 (19)
epidural analgesia (TEA),
intrathecal morphine (ITM), and Age (yr) 63 (34–83) 61 (20–81) 60 (25–86)
patient-controlled analgesia Gender: male 26 (51) 45 (57) 16
(PCA) alone groups Weight (kg) 74 (45–122) 76 (48–124) 83 (36–145)
Procedure
Pancreaticoduodenectomy 19 (37) 18 (23) 5
Hepatectomy 15 (29) 29 (37) 9
Data are shown as median Other 17 (33) 29 (37) 17
(range) or number (%) ASA score 1–2 33 (65) 62 (78) 15*
P = not significant for all Operation time (min) 275 (95–680) 240 (70–540) 195 (55–495)
variables except where
Blood loss (ml) 350 (15–4000) 300 (50–2000) 125 (50–300)*
indicated by * where P \ 0.05

123
World J Surg (2009) 33:1802–1808 1805

Table 4 Summary of additional analgesia used for patients receiving thoracic epidural analgesia (TEA), intrathecal morphine (ITM), or patient-
controlled analgesia (PCA) alone
Additional analgesia TEA (n = 51) ITM (n = 79) PCA (n = 31) P value

Opiates/opiate derivatives
Morphine/fentanyl 4 (2) 13 (16) 5 0.34
Codeine 1 (0.5) 6 (5) 1 0.31
Tramadol 1 (0.5) 4 (3) 1 0.65
NSAIDs 1 (0.5) 33 (42) 4 \0.001
Clonidine 1 (0.5) 8 (10) 8 0.003
Ketamine 0 1 (1) 2 0.10
Other 1 (0.5) 2 (3) 4 0.03
Nonsteroidal anti-inflammatories (NSAIDs) included Diclofenac or Ibuprofen. Note that for some patients, more than one type of additional
analgesic agents may have been used
Data are shown as number (%)

Additional analgesia in the form of oral nonsteroidal Table 5 Summary of major complications for the thoracic epidural
anti-inflammatories, oral opiates or opiate derivatives, analgesia (ITM) and intrathecal morphine (ITM) groups
intravenous opiates, or sedatives in ICU were used on a
Variable TEA ITM P value
regular or as-required basis in 8 of 51 (16%) patients in the (n = 51) (n = 79)
TEA group and 54 of 79 (68%) in the ITM group
(P \ 0.001; Table 4). A continuous morphine infusion was Surgical 15 (29) 24 (30) 0.90
used in two patients (1 in the ITM and 1 in the PCA group); Post-operative bleeding 0 4 (5) 0.10
both of these patients had undergone a palliative double Anastomotic leak 4/30 5/42 0.74
bypass. Wound catheters were used in 1 (2%) patient in the Abdominal collection 5 (10) 2 (3) 0.07
TEA group and 43 (54%) patients in the ITM group Pancreatic fistula 3/26 1/27 0.31
(P \ 0.001). Comparing those patients who received PCA Wound infection 3 (6) 3 (4) 0.58
alone before and after the introduction of ITM, more Other 6 (12) 11 (14) 0.58
patients had wound catheters after June 2006 (before Nonsurgical
change 4/16 vs. after change 12/15, P \ 0.01); however, Respiratory depression 0 3 (4) 0.16
oral analgesic administration postoperatively was unchan- Respiratory complication 5 (10) 1 (1) 0.02
ged (before change 7/16 vs. after change 11/15, P = 0.09). Postoperative 21 (41) 7 (9) \0.001
The incidence of postoperative hypotension was signif- hypotension
icantly higher in the TEA group (21/51 (41%) vs. 7/79 Death 2 (4) 2 (3) 0.65
(9%); P \ 0.001). A median of 6 (range, 3–11) liters of Note that some patients may have had more than one complication
intravenous fluid was given during the first 24 h to those Data are shown as number (%) or n/number of procedures where the
patients who received TEA compared with 5 (range, 3–11) complication is a recognized risk
liters for those who received ITM (P \ 0.05). The median
total intravenous fluid used in the TEA group was 15.5 There were five inpatient deaths: two in the TEA, one in
(range, 5–48.5) liters compared with 9 (range, 3–70) liters the PCA, and two in the ITM group (Table 5). In the TEA
for those who received ITM (P \ 0.001). Comparing group, the first was due to multiorgan failure after pul-
patients who received PCA alone before and after the monary aspiration after pancreaticoduodenectomy with
introduction of ITM, there was no significant difference in vascular reconstruction and the second due to postoperative
median total intravenous fluid administration (before pneumonia (respiratory complication). The death in the
change 11 (range, 5.5–50) liters vs. after change 11 (range, PCA group was the result of advanced malignancy. In the
4–65) liters; P = 0.74). ITM group, one death was due to hepatic failure after
Three patients in the ITM group had an episode of hepatectomy and the second patient died on the day or
opioid-induced respiratory depression, requiring treatment surgery after an intraoperative myocardial infarction and
with Naloxone and intensive monitoring (Table 5). These subsequent multiorgan failure. Table 5 shows a summary
events occurred on the surgical ward, less than 24 h after of all complications.
surgery. The patients had received large doses of intrave- There were no respiratory complications in the PCA
nous opiates in recovery (10–15 mg of morphine), in group. Comparing those patients who received PCA alone
addition to intraoperative systemic opiate. before and after the introduction of ITM, there was no

123
1806
Fig. 1 Hospital stay as subgrouped by surgical procedure; roof-top
incisions only were included comparing thoracic epidural analgesia
(TEA) with intrathecal morphine (ITM). Box plots are median (values
are indicated in black), interquartile range, and 90% confidence
interval
significant difference in surgical complications (before
change 3/15 vs. after change 5/16, P = 0.47).
Patients who received TEA had a median hospital stay
of 9 (range, 3–36) days, which was longer than for patients
receiving ITM who had a median stay of 7 (range, 3–55)
days (P \ 0.01). Subgroup analysis by operation type
(pancreaticoduodenectomy, hepatectomy, other) versus
hospital stay showed a shorter admission for all patients
except those who underwent a pancreaticoduodenectomy
(Fig. 1).
Comparing patients who received PCA alone before and
after the introduction of ITM, there was no significant
difference in the length of hospital stay between these two
PCA alone groups (before change 7 (range, 4–27) days vs.
after change 8 (range, 3–56) days (P = 0.65).
Discussion
The current retrospective study has shown that ITM for
major HPB surgery is associated with a lower incidence of
postoperative hypotension, reduced perioperative intrave-
nous fluid requirement, and shorter hospital stay compared
with TEA. These findings have important resource impli-
cations for surgical services.
Increasingly, the trend to reduce the length of hospital
stay with fast-track or enhanced recovery surgery is being
introduced for major abdominal surgery [6]. Several trials
that compare fast-track protocols have shown a median
hospital stay for patients across a wide range of operation
types to be in the region of 3–4 days [25–29]. The current
study demonstrated a reduction in median hospital stay of
3.5 days for patients after major hepatic resection with use
123
World J Surg (2009) 33:1802–1808
of ITM compared with epidural. The reduction of hospital
stay in the ITM group is unlikely to be solely related to
continually changing hospital practice given that those
patients who received PCA alone showed no difference in
median hospital stay before and after the introduction of
ITM. It is likely that the reduction in hospital stay for the
ITM group is multifactorial and includes factors, such as
quality of analgesia, reduced postoperative intravenous
fluid, and absence of epidural motor block allowing for
early mobilization. It is interesting to note that although the
reduced hospital stay was seen with both hepatectomies
and other types of HPB surgery, it was not seen with
pancreaticoduodenectomy. This is not surprising given the
rate limiting step for patients after pancreaticoduodenec-
tomy is the presence or absence of complications as
opposed to analgesic requirements.
Postoperative hypotension was significantly more com-
mon in the TEA group as was the use of intravenous fluids
during both the first 24 h postoperatively and in total.
Postoperative hypotension after epidural has been previ-
ously well documented [5, 7]. Respiratory complications
were more common in the TEA group compared with the
ITM group. Meta-analysis has shown that opioid TEA
compared with systemic opioid can decrease the incidence
of pulmonary morbidity [2]. Thus ITM proves a favorable
choice in minimizing respiratory complications as well as
postoperative hypotension and intravenous fluid use.
Conversely, respiratory depression continues to remain a
risk with ITM use. ITM has been associated with respira-
tory depression and sedation particularly when combined
with high doses of intravenous opiates [23]. Although
respiratory depression was more common in the ITM
group, this result did not attain statistical significance. This
may be due to the additional administration of regular
nonopiate systemic analgesia in combination with the use
of wound catheters (their use increased after the introduc-
tion of ITM as shown for the PCA alone group). Others
have found that wound perfusion with local anesthetic had
no beneficial effect on the postoperative respiratory func-
tion [30]. However, wound catheters have recently been
shown to be a safe and efficient method for reducing VAS
for pain and opioid requirements during the early postop-
erative period as well as reducing the duration of ileus and
length of hospital stay, resulting in earlier ambulation for
patients undergoing colorectal surgery [30–32]. Adminis-
tration of regular nonopiate systemic analgesia, such as oral
NSAIDs, Clonidine, and others, was more common in the
ITM group compared with the TEA group (Table 4). It is
possible that the addition of these adjunct analgesics to the
TEA group might have resulted in improved analgesia and
less epidural-related side effects.
Because of the retrospective nature of this study, the
quality of pain relief could not be objectively assessed,
World J Surg (2009) 33:1802–1808
making it impossible to know whether the patients in each
group received equivalent analgesia particularly given the
24-h limit on narcotic use in the ITM group. Previous
studies have shown that pain evaluation on the VAS was
lower or equivalent in patients who received ITM com-
pared with PCA alone [23] without such a limit in place.
Comparison of ITM with epidural analgesia for postoper-
ative pain relief after liver resection showed the VAS
remained similar throughout the 48-h postoperative period;
however, PCA morphine consumption was higher in the
ITM group [23]. The amount of analgesic administered via
PCA could not be calculated in this study because of the
variability of PCA content; future prospective studies will
need to address this issue.
Locally two important limitations in the use of TEA
existed: first, a lack of resource to allow the use of vaso-
constrictors for the treatment of hypotension in the surgical
ward setting, and second, medical response times for out of
hours management of epidurals and epidural top-ups are
dependant on theatre activity that may cause delays in
attendance to epidurals. The epidural protocol of the cur-
rent study reflects the difficulties and practicalities that are
encountered with epidural use in day-to-day clinical prac-
tice where resource constraints are present. The use of ITM
reduces this potential resource utilization as well as being
associated with an overall resource use reduction as seen in
the shortened hospital stay. Ideally randomized, prospec-
tive studies should be performed to determine the exact
role of ITM compared with TEA for procedure-specific
fast-track abdominal surgery.
Conclusions
A change in practice from TEA to ITM for major HPB
surgery at Christchurch hospital was associated with a
lower occurrence of postoperative hypotension and respi-
ratory complication. In a resource-limited setting, ITM
when compared with TEA is associated with reduced
postoperative intravenous fluid requirement and hospital
stay.
References
1. Werawatganon T, Charulusanun S (2005) Patient controlled
intravenous opioid analgesia versus continuous epidural analgesia
for pain after intra-abdominal surgery. Cochrane Database Syst
Rev 25:CD004088
2. Ballantyne JC, Carr DB, de Ferranti S, Suarez T, Laau J, Chalmers
TC et al (1998) The comparative effects of postoperative anal-
gesic therapies on pulmonary outcome: cumulative meta-analyses
of randomized, controlled trails. Anesth Analg 86:598–612
1807
3. Beattie SW, Badner NH, Choi P (2001) Epidural analgesia
reduces postoperative myocardial infarction: a meta-analysis.
Anesth Analg 93:853–858
4. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert
A et al (2000) Reduction of postoperative mortality and mor-
bidity with epidural or spinal anaesthesia: results from overview
of randomised trials. BMJ 321:1493–1497
5. Rigg JR, Jamrozik KM, Myles PS, Silbert BS, Peyton RJ, Parsons
RW et al (2002) Epidural anaesthesia and analgesia and outcome
of major surgery: a randomised trial. Lancet 359:1276–1282
6. Wind J, Polle SW, Fung Kon Jin PHP, Dejong MF, von
Meyenfeldt DT et al (2006) Systematic review of enhanced
recovery programmes in colonic surgery. Br J Surg 93:800–809
7. Conacher ID, Paes ML, Jacobson L, Phillips PD, Heaviside DW
(1983) Epidural analgesia following thoracic surgery: a review of
2 years’ experience. Anaesthesia 38:546
8. Redai I, Emond J, Brentjens T (2004) Anaesthetic considerations
during liver surgery. Surg Clin North Am 84:401–411
9. Power GE, Warden B, Cooke K (2005) Changing patterns in the
acute pain service: epidural versus patient-controlled analgesia.
Anaesth Intensive Care 33:501–505
10. Wang JN, Thomas LA (1979) Pain relief by intra-thecally applied
morphine in man. Anesthesiology 50:149–151
11. Samii K, Chauvin M, Viars P (1981) Postoperative spinal anal-
gesia with morphine. Br J Anaesth 53:817–820
12. Jacobson L, Chabal C, Brody MC (1988) A dose-response study
of intra-thecal morphine: efficacy, duration, optimal dose, and
side effects. Anesth Analg 67:1082–1088
13. Rawal N (2002) Incisional and intra-articular infusions. Best
Practice Res Clin Anaesthesiol 16:321–343
14. Swart M, Sewell J, Thomas D (1997) Intra-thecal morphine for
caesarean section: an assessment of pain relief, satisfaction and
side-effects. Anaesthesia 52:373–377
15. Weber EW, Slappendel R, Gielen MJ, Dirksen R (1998) Intra-
thecal addition of morphine to bupivacaine is not the cause of
postoperative nausea and vomiting. Reg Anesth Pain Med 23:
81–86
16. Gwirtz KH, Young JV, Byers RS, Alley C, Levin K, Walker SG
et al (1999) The safety and efficacy of intra-thecal opioid analgesia
for acute postoperative pain: seven years’ experience with 5969
surgical patients at Indiana University Hospital. Anesth Analg 88:
599–604
17. Devys JM, Mora A, Plaud B, Jayr C, Laplanche A, Raynard B,
Lasser P, Debaene B (2003) Intra-thecal ? PCA morphine
improves analgesia during the first 24 hr after major abdominal
surgery compared to PCA alone. Can J Anaesth 50:355–361
18. Cole PJ, Craske DA, Wheatley RG (2000) Efficacy and respira-
tory effects of low-dose spinal morphine for postoperative anal-
gesia following knee arthroplasty. Br J Anaesth 85:233–237
19. Fleron MH, Weiskopf RB, Bertrand M, Mouren S, Eyraud D,
Godet G et al (2003) A comparison of intra-thecal opioid and
intravenous analgesia for the incidence of cardiovascular, respi-
ratory, and renal complications after abdominal aortic surgery.
Anesth Analg 97:2–12
20. Blay M, Orban JC, Rami L, Gindre S, Chambeau R, Batt M,
Grimaud D, Ichai C (2006) Efficacy of low-dose intra-thecal
morphine for postoperative analgesia after abdominal aortic
surgery: a double-blind randomized study. Reg Anesth Pain Med
31:127–133
21. Beaussier M, Weickmans H, Parc Y, Delpierre E, Camus Y,
Funck-Brentano C, Schiffer E, Delva E, Lienhart A (2006)
Postoperative analgesia and recovery course after major colo-
rectal surgery in elderly patients: a randomized comparison
between intra-thecal morphine and intravenous PCA morphine.
Reg Anesth Pain Med 31:531–538
123
1808
22. Rawal N, Arner S, Gustafsson LL, Allvin R (1987) Present state
of extradural and intra-thecal opioid analgesia in Sweden. A
nationwide follow-up survey. Br J Anaesth 59:791–799
23. De Pietri L, Siniscalchi A, Reggiani A, Masetti M, Begliomini B,
Gazzi M et al (2006) The use of intra-thecal morphine for post-
operative pain relief after liver resection: a comparison with
epidural analgesia. Anesth Analg 102:1157–1163
24. Ministry of Health, National Ethics Advisory Committee, Ethical
Guidelines for Observational Studies http://www.neac.health.
govt.nz. Accessed 2003
25. Delaney CP, Fazio VW, Senagore AJ, Robinson B, Halverson
AL, Remzi FH (2001) ‘‘Fast track’’ postoperative management
protocol for patients with high co-morbidity undergoing complex
abdominal and pelvic colorectal surgery. Br J Surg 88:1533–1538
26. Fearon KC, Ljunggvist O, Von Meyenfeldt M, Revhaug A, De-
jong CH, Lassen K, Nygren J et al (2005) Enhanced recovery
after surgery: a consensus review of clinical care for patients
undergoing resection. Clin Nutr 24:466–477
27. Basse L, Thorbol JE, Lossi K, Kehlet H (2004) Colonic surgery
with accelerated rehabilitation or conventional care. Dis Colon
Rectum 47:271–277
123
World J Surg (2009) 33:1802–1808
28. King PM, Blazeby JM, Ewings P, Longman RJ, Kipling RM,
Franks PJ et al (2006) The influence of an enhance recovery
programme on clinical outcomes, costs and quality of life after
surgery for colorectal cancer. Colorectal Dis 8:506–513
29. Nygren J, Hausel J, Kehlet H, Revhaug A, Lassen K et al (2005) A
comparison in five European centres of case mix, clinical man-
agement and outcomes following either conventional or fast-track
preoperative care in colorectal surgery. Clin Nutr 24:455–461
30. Sistla SC, Sibal AK, Ravishankar M (2009) Intermittent wound
perfusion for postoperative pain relief following upper abdominal
surgery: a surgeon’s perspective. Pain Pract 9:65–70
31. Baig MK, Zmora O, Derdemezi J, Weiss EG, Nogueras JJ, Wexner
SD (2006) Use of the ON-Q pain management system is associated
with decreased postoperative analgesic requirement: double blind
randomized placebo pilot study. Am Coll Surg 202:297–305
32. Liu SS, Richman JM, Thirlby RC, Wu CL (2006) Efficacy of
continuous wound catheters delivering local anesthetic for post-
operative analgesia: a quantitative and qualitative systematic
review of randomized controlled trials. J Am Coll Surg 203:
914–932