Enhanced Recovery After Surgery: Is a Combination of Intrathecal Opioid with Rectus Sheath Catheter a Better Alternative than an Epidural in Major Gynaecological - Oncology Surgeries?

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Background and Goals
Enhanced Recovery After Surgery (ERAS) is increasingly used in many other surgical specialties for encouraging a more rapid postoperative recovery but has been slow to implement in gynaecological-oncology (1) . Gynaecological-oncology surgery has made significant advances in diagnostic and operative techniques, yet advances in length of stay (LOS) and postoperative activity are yet to be seen. The objective of this study was to evaluate the influence of analgesia regimes in order to tailor an ERAS protocol specifically for this cohort of patients. Traditionally this group of patients received the current accepted standard of a general anaesthesia (GA) with thoracic epidural (TEA) – Group 1(2). We proposed a modified ERAS protocol with analgesic premedication, intraoperative neuroaxial block (spinal with diamorphine) alongside the GA and postoperative rectus sheath catheters (RSC) (Bbraun On Q Pain Buster), with oral analgesia – Group 2. 
Methods 
This involved a combination of an audit and observational study. There was retrospective and prospective data collection, of 86 patients who had undergone surgery over the last 12 months. The goal was to compare and contrast the proposed ERAS protocol with current practice in patients with incisions below T9, with particular focus on pain scores and postoperative activity times for, both of which directly impact length of stay (3). Data was analysed using excel and all statistics were performed using Minitab 12 with a combination of two sample T test and ANOVA GLM. 
Results 
32 retrospective 31 prospective patient records were included in the final results. Average age and surgical time for group 2 was 61 years and 169 Minutes , For group 1 58 Years and 252 Minutes. 
Results showed that there was statistically better pain scores for group 2,  at 36 48 and 72 hours indicating an approach of a spinal + RSC is superior to GA+TEA (Figure 1). 
In addition there was a significant improvement in all-postoperative activities in group 2(Figure 2)
There was no statistically significant difference in postoperative patient satisfaction scores, complications or nausea and vomiting between the two groups.

Enhanced recovery after surgery: is a combination of intrathecal opioid with rectus sheath catheter a better alternative than an epidural in major gynaecological - oncology surgeries?