Postoperative Pain Treatment After Pancreatic Surgery: A Systematic Review With Meta-Analyses and Trial Sequential Analyses

Abstract

Background

Major pancreatic surgery is associated with significant postoperative pain that impairs early mobilisation and recovery. ERAS guidelines for pancreaticoduodenectomy recommend multimodal opioid-sparing analgesia, with a strong recommendation for epidural analgesia and continuous wound infiltration as an alternative. Other techniques may be beneficial, but their efficacy and safety remain uncertain.

Objective

To investigate the efficacy and adverse events of different postoperative analgesic modalities for patients undergoing total pancreatectomy, pancreaticoduodenectomy and distal pancreatectomy.

Databases and Data Treatment

This PROSPERO-registered systematic review (ID CRD420251085003) reported in accordance with the PRISMA guidelines. A search for randomised controlled trials was conducted in Medline, Cochrane Central Register of Controlled Trials and Embase. Meta-analyses were performed in Review Manger, risk of bias was assessed with RoB 2, trial sequential analyses were performed, and the certainty of evidence was evaluated using GRADE.

Results

Eighteen RCTs comprising 1468 patients were included, and 10 meta-analyses were performed. Meta-analyses demonstrated reduced pain scores at rest on postoperative day (POD) two with COX-inhibitors compared with placebo/no intervention. Pain scores were similar when comparing epidural analgesia with less invasive strategies (paravertebral block and wound infiltration) on POD1–POD2, but lower with the less invasive techniques on POD3. Meta-analyses were small, and GRADE recommendations ranged from very low to low.

Conclusions

The available evidence was insufficient to establish the superiority of any single analgesic strategy after major pancreatic surgery. Several analgesic strategies, including COX inhibitors, paravertebral block and continuous wound infiltration, showed promising results. Larger RCTs are needed to provide stronger evidence-based recommendations.

Significance Statement

Epidural analgesia has long been considered the gold standard for treatment of postoperative pain after major pancreatic surgery. The present review adds to the field by demonstrating that less invasive strategies as continuous wound infiltration and paravertebral block provide comparable pain scores in the first postoperative days, with a significantly lower score on postoperative day three. This supports positioning less invasive strategies as viable alternatives to epidural analgesia.