The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patients .
This finding may become irrelevant because of rapid conversion of major surgery to minimally invasive techniques ( e.g. , endoluminal abdominal aortic repair ) that carry less risk of complications .
There is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery .
Again , this finding may also become irrelevant with the adoption of laparoscopic techniques and multimodal fast-track programs for abdominal surgery .
There is no current evidence that perineural analgesia , continuous wound catheters using local anesthetics , IV patient-controlled analgesia with opioids , or addition of multimodal systemic analgesics have any clinical ly significant beneficial effect on postoperative complications .
CONCLUSIONS : Overall , there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity .
This is primarily due to typically insufficient subject numbers to detect differences in currently low incidences of postoperative complications
BACKGROUND : Few individual clinical trials have had sufficient subject numbers to definitively determine the effects of postoperative analgesia on major outcomes .
Epidural analgesia with local anesthetics has the greatest theoretical potential to affect major outcomes and has been the most thoroughly investigated technique .
Epidural anaesthesia and analgesia and outcome of major surgery: a randomised trial
BACKGROUND Epidural block is widely used to manage major abdominal surgery and postoperative analgesia , but its risks and benefits are uncertain . We compared adverse outcomes in high-risk patients managed for major surgery with epidural block or alternative analgesic regimens with general anaesthesia  in a multicentre r and omised trial . METHODS 915 patients undergoing major abdominal surgery with one of nine defined comorbid states to identify high-risk status were r and omly assigned intraoperative epidural anaesthesia and postoperative epidural analgesia for 72 h with general anaesthesia ( site of epidural selected to provide optimum block ) or control . The primary endpoint was death at 30 days or major postsurgical morbidity . Analysis by intention to treat involved 447 patients assigned epidural and 441 control . FINDINGS 255 patients ( 57.1 % ) in the epidural group and 268 ( 60.7 % ) in the control group had at least one morbidity endpoint or died ( p=0.29 ) . Mortality at 30 days was low in both groups ( epidural 23 [ 5.1 % ] , control 19 [ 4.3 % ] , p=0.67 ) . Only one of eight categories of morbid endpoints in individual systems ( respiratory failure ) occurred less frequently in patients managed with epidural techniques ( 23 % vs 30 % , p=0.02 ) . Postoperative epidural analgesia was associated with lower pain scores during the first 3 postoperative days . There were no major adverse consequences of epidural-catheter insertion . INTERPRETATION Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia . However , the improvement in analgesia , reduction in respiratory failure , and the low risk of serious adverse consequences suggest that many high-risk patients undergoing major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative epidural analgesia
The majority of evidence favors an ability of epidural analgesia to reduce postoperative cardiovascular and pulmonary complications only after major vascular surgery or in high-risk patients .
This finding may become irrelevant because of rapid conversion of major surgery to minimally invasive techniques ( e.g. , endoluminal abdominal aortic repair ) that carry less risk of complications .
There is also consistent evidence that epidural analgesia with local anesthetics is associated with faster resolution of postoperative ileus after major abdominal surgery .
Again , this finding may also become irrelevant with the adoption of laparoscopic techniques and multimodal fast-track programs for abdominal surgery .
There is no current evidence that perineural analgesia , continuous wound catheters using local anesthetics , IV patient-controlled analgesia with opioids , or addition of multimodal systemic analgesics have any clinical ly significant beneficial effect on postoperative complications .
CONCLUSIONS : Overall , there is insufficient evidence to confirm or deny the ability of postoperative analgesic techniques to affect major postoperative mortality or morbidity .
This is primarily due to typically insufficient subject numbers to detect differences in currently low incidences of postoperative complications
BACKGROUND : Few individual clinical trials have had sufficient subject numbers to definitively determine the effects of postoperative analgesia on major outcomes .
Epidural analgesia with local anesthetics has the greatest theoretical potential to affect major outcomes and has been the most thoroughly investigated technique .