Abstract
Background and Aims:
Thoracic continuous spinal anaesthesia (TCSA) avoids airway instrumentation and mechanical ventilation and may provide better postoperative pulmonary outcomes compared to general anaesthesia (GA) with thoracic epidural analgesia (TEA) for patients requiring laparotomy. The study compared postoperative pulmonary functions and outcomes between these two anaesthesia techniques.
Methods:
Sixty adults were randomly assigned to Group GA+TEA or Group TCSA. In Group GA+TEA, the TEA was secured through the T9-T10 level, followed by GA. A 25-G catheter was placed at the same level in Group TCSA, and they received all preservative-free drugs (0.5% plain bupivacaine with 0.25 mg/kg ketamine and 0.03 mg/kg midazolam) to achieve a sensory block from T4 to L1. The primary outcome assessed was peak expiratory flow rate (PEFR) over the 72 h postoperative period. The secondary outcomes assessed were breath-holding time (BHT), lung atelectasis, and change in transdiaphragmatic excursion. The two-sided Student t-test, Mann–Whitney test, and Chi-squared test were used to analyse the data.
Results:
The PEFR was reduced in both groups from baseline (P < 0.001), with no difference between them (P = 0.498). However, Group TCSA showed significantly better outcomes concerning BHT on postoperative days (POD) 1 and 2 (P = 0.048 and P = 0.005, respectively), reduced lung atelectasis at 1 h postoperatively (P = 0.03), and greater diaphragmatic excursion at 1 h, POD 1 and 2 (P < 0.001).
Conclusion:
In patients undergoing major abdominal surgery, the PEFRs during the postoperative period were comparable for GA with thoracic epidural versus thoracic continuous spinal anaesthesia.
Keywords: Epidural anaesthesia, peak expiratory flow rate, postoperative complications, postoperative nausea and vomiting, pulmonary atelectasis, pulmonary function test, spinal anaesthesia, thoracic continuous spinal anaesthesia
INTRODUCTION
General anaesthesia (GA) with thoracic epidural is a well accepted anaesthesia technique for major abdominal surgery. However, it adversely affects lung mechanics and gas exchange. GA suppresses central respiratory drive and reduces ventilatory responses to hypoxia and hypercapnia. The upward movement of the diaphragm in the supine position results in a decline in functional residual capacity (FRC) by 15–20%.[1] These changes promote atelectasis and impair the ventilation perfusion quotient (V/Q).[1] Risk factors like advanced age, high American Society of Anesthesiologists physical status (ASA-PS) ≥III, preexisting respiratory illness, sleep apnoea, and surgical complexity contribute to the advancement of postoperative pulmonary complications (PPC), with the incidence ranging from 9% to 40%.[2] Preventive strategies such as smoking cessation, airway hydration, bronchodilators, and incentive spirometry aim to optimise pulmonary recovery.[3,4] Thoracic epidural analgesia (TEA) facilitates patients to cough and deep breathing and may reduce the incidence of PPCs.[5,6]
We hypothesised that thoracic continuous spinal anaesthesia (TCSA) may preserve or improve pulmonary function and outcomes by eliminating the need for airway instrumentation and mechanical ventilation. The primary objective of this study was to compare peak expiratory flow rate (PEFR) at multiple predefined time points [T0: preoperative period, T1: 1-h postoperative period, T2/T3/T4: day (POD) 1, 2, and 3, respectively] in patients requiring open abdominal surgery between GA+TEA and TCSA. Secondary objectives included comparisons of breath-holding time (BHT), oxygen saturation (SpO2), incidence of lung atelectasis and other pulmonary complications (e.g., pleural effusion, pneumonia, adult respiratory distress syndrome, etc.), transdiaphragmatic excursion (∆TDI), and overall, in-hospital morbidities.
METHODS
This single-blinded, randomised controlled trial (RCT) was approved from the Institutional Ethics Committee (vide approval number AIIMS/IEC/23/484 dated 08 December 2023) and was registered with the Clinical Trials Registry-India (vide registration number CTRI/2024/02/062705 dated 15 February 2024, accessible at www.ctri.nic.in). The study was conducted between March 2024 and February 2025, in accordance with the principles of the Declaration of Helsinki, 2013 and Good Clinical Practice guidelines. After explaining the study protocol, written informed consent was obtained for participation in the study and use of the patient data for research and educational purposes.
The study included individuals who were over 18 years of age and required an elective major open abdominal surgery, both males and females, classified as ASA-PS I–III. Excluded from the study were participants with a body mass index (BMI) >35 kg/m2, participants suffering from severe systemic illnesses, pregnant women, those with any contraindications to spinal anaesthesia, and haemodynamically unstable patients.
All patients underwent a comprehensive assessment before their recruitment for airway and spine anatomy, evaluation of the likelihood of having respiratory complications [using the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT score)] and systemic illness (as measured by the Charlson’s Comorbidity Index), along with their current status. Bedside pulmonary function tests, including PEFR (via a handheld peak flowmeter), BHT, SpO2, lung ultrasound (LUS) parameters, and diaphragmatic excursion, were performed. Patients were also familiarised with the pain scales [numerical rating scale (NRS)]. All patients were kept nil per oral as per standard protocol.
Sixty patients (30 from each group) in need of abdominal surgery were recruited. Randomisation was performed using Research Randomiser version 4.0 (Urbaniak and Plous, 2013; http://www.randomizer.org/) by an independent staff member not otherwise involved in the study. Central randomisation ensured allocation concealment and parallel distribution of participants into two equal groups: GA+TEA and TCSA. Group assignments were revealed by a separate investigator with no further role in the trial, while both patients and outcome assessors were kept blinded to allocation. Standard ASA monitoring was done throughout surgery, and adequate intravenous (IV) access was secured. Central venous access, arterial blood gas, and invasive blood pressures were monitored when indicated.
In Group GA+TEA, an epidural catheter was secured through the T9–T10 interspace using an 18-G Tuohy needle and a 20-G catheter (Portex, London, United Kingdom). An epidural test dose consisting of 3 mL of 2% lignocaine with 15 μg of adrenaline was administered to verify its placement. Intraoperative analgesia was provided with 0.1% levobupivacaine (10 mL) with 2 μg/mL of fentanyl, followed by a continuous infusion at a rate of 10–12 mL/h using a syringe pump (Mindray, Shenzhen, China), adjusted according to haemodynamic parameters. GA was initiated with standard doses of IV fentanyl, propofol, and vecuronium to assist tracheal intubation. The anaesthesia was maintained using sevoflurane (1.5–3.0%) in a 50:50 mixture of oxygen and air, targeting a minimum alveolar concentration (MAC) of 1.0. Mechanical ventilation was implemented using lung protective strategies [tidal volumes: 6–8 mL/kg of predicted body weight, PEEP: 5–8 cm H2O, and respiratory rate (RR) adjusted to achieve an end-tidal carbon dioxide (EtCO2) level of 35–45 mmHg].
Following the conclusion of surgery, inhalational anaesthetics were discontinued, and the residual neuromuscular blockade was pharmacologically reversed. The tracheal extubation was performed once the patient demonstrated adequate spontaneous ventilation, sustained head lift, and responsiveness to verbal commands, confirming full recovery from anaesthesia. Postoperative pain management involved a continuous epidural infusion of 0.1% levobupivacaine in combination with fentanyl (2 μg/mL) at a rate of 10–12 mL/h, delivered through an elastomeric pump (Smiths Neofuser, London, England) for a period of 72 hours.
TCSA (Group TCSA) was commenced with IV co-loading using Ringer’s lactate at a dosage of 20 mL/kg. The T9–T10 intervertebral space was located after the area was cleaned and draped, and a 21-G spinal needle (Sprotte tip) (PAJUNK, Geisingen, Germany) was advanced until cerebrospinal fluid (CSF) flowed freely; subsequently, the spinal catheter (25G) was advanced 4–5 cm in a cephalad direction. The intrathecal induction process included the administration of preservative-free ketamine at a dosage of 0.25 mg/kg and midazolam at 0.03 mg/kg as adjuncts. This was succeeded by incremental doses of 2.5 mg of 0.5% isobaric levobupivacaine every 3 minutes until a sensory block from T4 to L1 levels was confirmed through cold touch and pinprick testing. Block maintenance included hourly intrathecal infusion of the same amount of local anaesthetic through a syringe pump. The sedation scores (Ramsay Sedation Score) were maintained between 2 and 3.
The spinal catheter was replenished when patients reported pain scores (NRS) >4 or if the sensory block diminished by two dermatomal segments. In such cases, 0.5 mL (2.5 mg) of the local anaesthetic was given every 3 minutes until adequate analgesia was achieved or the target sensory level was restored. In cases where pain continued despite the aforementioned interventions, IV fentanyl was administered at a dosage of 0.5 μg/kg as a form of rescue analgesia. The need for sedation and the use of rescue analgesics were recorded. The rescue sedation was administered by IV dexmedetomidine 0.2–07 μg/kg/hr infusion. Criteria for conversion to GA included inadequate block height, haemodynamic instability unresponsive to fluids and vasopressors, apnoea, or patient discomfort.
Postoperative pain management was provided via the intrathecal catheter using levobupivacaine (0.1%) and fentanyl (2 μg/mL) at of 2–4 mL/h. This process commenced at roughly 30 minutes before the closure of skin and was sustained for a duration of 72 hours by an elastomeric pump (Smiths Neofuser, London, England).
Postoperative monitoring included the assessment of vital signs every hour. Prophylaxis for postoperative nausea and vomiting included IV ondansetron (0.1 mg/kg) thrice a day, and multimodal analgesia with IV paracetamol (1 g four times a day) with IV diclofenac (75 mg twice a day) in addition to continuous epidural or intrathecal analgesia. The following outcome parameters were assessed in the postoperative period: PEFR (primary outcome) was assessed after training the patients to use the peak expiratory flow meter (Cipla Breath-O-Meter), and was measured after maximal inspiration with rapid, forceful expiration. The other secondary outcomes were BHT recorded from deep inspiration to the onset of involuntary breathing after they were trained to perform the same. Lung ultrasound was performed in supine position with B-mode and M-mode using a 3–5 MHz curvilinear probe (Sonosite, Edge-II, Washington, USA). Atelectasis was defined as tissue-like echotexture on B-mode with static air bronchograms on M-mode, and pleural effusion as an anechoic space between pleural layers.[7] Diaphragmatic excursion was measured below the costal margin using M-mode during deep respiration.[8] These parameters were recorded at 1 h postoperative period, POD 1, 2, and 3. Postoperative pain was evaluated using NRS at 0, 24, 48, and 72 hours. Additional outcomes recorded included bowel function return, mobilisation, hospital stay duration, in-hospital morbidity (requirement for ICU care, mechanical ventilation), and in-house mortality. Hypotension, defined as MAP <65 mmHg or SBP <90 mmHg, was initially managed with a 250 mL intravenous crystalloid bolus. If unresponsive, incremental IV boluses of mephentermine (3–6 mg, up to 30 mg) were administered. Persistent hypotension was treated with titrated doses of IV norepinephrine to maintain MAP >65 mmHg. By the time blood components arrived, 250 mL boluses of colloids were used to address hypotension caused by blood loss. Bradycardia, characterised by HR ≤50 beats/minute, was managed by 0.6 mg IV atropine. All haemodynamic events and corresponding interventions were documented and analysed for both groups.
Given the absence of existing literature comparing postoperative pulmonary function between two anaesthesia techniques (GA+TEA and TCSA) in patients undergoing major abdominal surgeries, all eligible patients undergoing such procedures during the 1 year were included. Altogether, 60 patients, with 30 from each group, took part in the study.
The Statistical Package for the Social Sciences (SPSS) statistics software, version 25.0 [International Business Machines Corporation (IBM Corp.), Armonk, NY, USA], was used to conduct statistical analyses. Continuous variables that adhered to a normal distribution (age) are represented as mean (standard deviation) and analysed using the two-sided Student’s t-test. Data exhibiting non-normal distribution (weight, BMI, Assess Respiratory Risk in Surgical Patients in Catalonia, and Charlson Comorbidity Index) are presented as median and range and evaluated using the Mann–Whitney U test. Categorical variables (such as gender) were assessed using either the Chi-square test or Fisher’s exact test, based on the context. A P value below 0.05 was regarded as indicative of statistical significance.
RESULTS
Sixty-four participants needing laparotomy were screened for eligibility, and 60 of them were analysed, 30 in each group [Figure 1]. Demographic and surgical variables were similar among the groups [Tables 1 and 2].
Figure 1.
Consolidated standard of reporting trials (CONSORT) flow chart
Table 1.
Demographic variables
| Variable | Group GA + TEA (n=30) | Group TCSA (n=30) | P |
|---|---|---|---|
| Age (years) | 48.03 (11.73) | 49.00 (12.88) | 0.762 |
| Gender (Male/Female) | 11/19 | 7/23 | 0.260 |
| Height (cm) | 158.13 (7.87) | 156.37 (7.24) | 0.369 |
| Weight (kg) | 57.5 (42-63.5) | 51.5 (47.2-58.7) | 0.695 |
| BMI (kg/m2) | 21.7 (17.7-25.5) | 20.9 (19.7-23.5) | 0.865 |
| ASA Physical Status (I/II/III) | 10/18/2 | 5/20/5 | 0.217 |
| Charlson Comorbidity Index | 2 (1.2-3) | 3 (1.2-3) | 0.184 |
| ARISCAT Score | 41 (38-49) | 39.5 (38-41.7) | 0.114 |
Data are expressed as Mean (standard deviation), median (interquartile range) or number (n). GA + TEA=General anesthesia +thoracic epidural anaesthesia; TCSA=Thoracic continuous spinal anesthesia; BMI=body mass index; ASA-PS=American Society of Anaesthesiologists physical status; ARISCAT=Assess Respiratory Risk in Surgical Patients in Catalonia
Table 2.
Surgical characteristics
| Parameter | Group GA + TEA (n=30) | Group TCSA (n=30) | P |
|---|---|---|---|
| Diagnoses (n/) | |||
| Carcinoma Gall Bladder | 10 | 7 | 0.165 |
| Carcinoma head of pancreas, Duodenal adenocarcinoma, Distal Cholangiocarcinoma | 7 | 5 | |
| Gall bladder wall thickening, Choledochal cyst, Xanthogranulomatous gallbladder | 2 | 5 | |
| Chronic calcific pancreatitis, Pancreatic pseudocyst | 3 | 3 | |
| Carcinoma colon, Rectosigmoid growth, Hepatic flexure adenocarcinoma | 1 | 4 | |
| Adnexal mass, Carcinoma ovary, Uterine fibroid | 2 | 2 | |
| Carcinoma stomach, Gastric outlet obstruction | 4 | 0 | |
| Benign biliary stricture, Bilio-vascular injury | 0 | 3 | |
| Hydatid cyst of liver | 1 | 0 | |
| Muscle-invasive bladder carcinoma | 0 | 1 | |
| Surgeries (n/) | |||
| Exploratory laparotomy, diagnostic laparoscopy with Radical cholecystectomy | 10 | 9 | |
| Gastrojejunostomy, Billroth II gastrectomy | 8 | 1 | |
| Open cholecystectomy, CBD exploration with Hepatico-jejunostomy | 3 | 6 | |
| Frey’s procedure, Open cystogastrostomy | 3 | 3 | |
| Right hemicolectomy, Anterior resection, Total proctocolectomy | 1 | 4 | 0.243 |
| Whipple’s procedure, Triple bypass | 2 | 3 | |
| Staging laparotomy, Cytoreductive surgery, Total abdominal hysterectomy | 2 | 2 | |
| Bilioenteric anastomosis | 0 | 1 | |
| Cystopericystectomy | 1 | 0 | |
| Radical cystectomy with Ileal conduit | 0 | 1 | |
| Duration of Anaesthesia (min) | |||
| Median (IQR) | 300 (235–360) | 275 (230–360) | 0.476 |
| Duration of Surgery (min) | |||
| Median (IQR) | 265 (186.25–310.00) | 235 (190.00–278.75) | 0.487 |
Data expressed numbers (n) and median (interquartile range). GA + TEA=General anaesthesia + thoracic epidural anaesthesia; TCSA=Thoracic continuous spinal anaesthesia; CBD=common bile duct; IQR=Interquartile range; n=number
Both groups exhibited a marked decline in PEFR immediately postoperatively, followed by gradual recovery, without any differences between the two anaesthesia techniques. However, substantially better outcomes were observed in Group TCSA concerning BHT on POD 1 (P = 0.044) and POD 2 (P = 0.005), indicating better preservation of respiratory function. Although baseline SpO2 was marginally lower for Group TCSA, the variability was statistically significant (P = 0.030), with postoperative values remaining comparable. The occurrence of atelectasis was less with Group TCSA at 1 hour postoperatively (10.0% vs 36.7%; P = 0.030), highlighting reduced early postoperative pulmonary compromise. Diaphragmatic excursion (∆TDI) was superior for Group TCSA at 1 h postoperative (P < 0.001). No differences were recorded in the occurrence of pleural effusion [Table 3].
Table 3.
Pulmonary functions and outcomes
| Time Point | Group GA + TEA (n=30) | Group TCSA (n=30) | Mean difference (95% CI) | P |
|---|---|---|---|---|
| PEFR (Litres/min) | ||||
| T0 | 215.67 (73.47) | 204.33 (63.55) | 11.33 (-24.18, 46.85) | 0.657 |
| T1 | 75.60 (58.88) | 74.64 (29.37) | 0.96 (-25.49, 27.41) | 0.606 |
| T2 | 96.67 (59.44) | 99.33 (43.15) | -2.67 (-29.56, 24.23) | 0.562 |
| T3 | 126.00 (58.52) | 128.00 (44.91) | -2.00 (-29.00, 25.00) | 0.598 |
| T4 | 162.67 (58.84) | 153.33 (45.51) | 9.33 (-17.89, 36.55) | 0.710 |
| BHT (seconds) | ||||
| T0 | 26.33 (6.30) | 27.17 (5.66) | -0.83 (-3.93, 2.26) | 0.362 |
| T1 | 9.68 (4.49) | 10.87 (4.76) | -1.19 (-3.62, 1.25) | 0.157 |
| T2 | 14.57 (4.94) | 17.20 (4.97) | -2.63 (-5.19, 0.07) | 0.044 |
| T3 | 17.67 (5.04) | 20.83 (4.08) | -3.17 (-5.54, -0.80) | 0.005 |
| T4 | 21.40 (5.04) | 22.87 (3.93) | -1.47 (-3.80, 0.87) | 0.214 |
| SpO2(%) | ||||
| T0 | 98.83 (0.75) | 97.97 (2.04) | 0.87 (0.06, 1.67) | 0.030 |
| T1 | 99.10 (0.92) | 99.17 (1.29) | -0.07 (-0.65, 0.51) | 0.596 |
| T2 | 98.70 (1.09) | 98.13 (1.31) | 0.57 (-0.05, 1.19) | 0.062 |
| T3 | 98.23 (0.86) | 98.07 (1.31) | 0.17 (-0.41, 0.74) | 0.932 |
| T4 | 95.13 (17.99) | 98.03 (1.50) | -2.90 (-9.64, 3.84) | 0.900 |
| Lung Atelectasis | ||||
| T0 | 0 (0%) | 0 (0%) | 0% (0%-0%) | 1.000 |
| T1 | 11 (36.7%) | 3 (10.0%) | 26.67% (63.5%, 46.98%) | 0.030 |
| T2 | 5 (16.7%) | 1 (3.3%) | -13.33% (-28.14%, o 1.47%) | 0.195 |
| T3/T4 | 0 (0%) | 0 (0%) | 0% (0%, 0%) | >0.99 |
| Pleural effusion | ||||
| T0 | 0 (0%) | 0 (0%) | 0.00% (0.00%-0.00%) | >0.99 |
| T1 | 0 (0%) | 0 (0%) | 0.00% (0.00%-0.00%) | >0.99 |
| T2 | 1 (3.3%) | 0 (0%) | -3.3% (-3.09%, 9.76%) | >0.99 |
| T3 | 3 (10.0%) | 0 (0%) | 10.00% (-0.74%, 20.74%) | 0.237 |
| T4 | 3 (10.0%) | 0 (0%) | 10.00% (-0.74%, 20.74%) | 0.237 |
| Trans-Diaphragmatic Excursion (ΔTDI) | ||||
| T0 | 0.45 (0.05) | 0.49 (0.07) | -0.04 (-0.10, -0.06) | 0.061 |
| T1 | 0.37 (0.04) | 0.44 (0.07) | -007 (-0.10, -0.04) | <0.001 |
| T2 | 0.42 (0.04) | 0.45 (0.06) | -0.03 (-0.09, -0.05) | 0.090 |
| T3 | 0.44 (0.04) | 0.47 (0.06) | -0.03 (-0.10, -0.06) | 0.100 |
| T4 | 0.44 (0.03) | 0.47 (0.06) | -0.03 (-0.10, -0.06) | 0.110 |
Data are expressed in mean (standard deviation), numbers (n), and percentage (%). GA + TEA=General anaesthesia + thoracic epidural anaesthesia; TCSA=Thoracic continuous spinal anaesthesia; PEFR=Peak expiratory flow rate; BHT=Breath holding time; SpO2=Oxygen saturation. T0=Preoperative, T1=1 hour postoperative, T2=Postoperative day 1, T3=Postoperative day 2, T4=Postoperative day 3
Bradycardia and atropine use were infrequent and comparable between groups (P = 0.612). However, Group TCSA experienced significantly more hypotensive episodes (P = 0.007) and required higher doses of mephentermine (P = 0.021) and colloid administration (P = 0.012). Intraoperative bleeding was slightly in excess in Group TCSA (P = 0.047). Differences in noradrenaline requirement, crystalloid volume, and urine output were not statistically significant [Table 4].
Table 4.
Intra-operative events
| Variable | Group GA + TEA (n=30) | Group TCSA (n=30) | Mean difference (95% CI) | P |
|---|---|---|---|---|
| Bradycardia | 1 (3.3%) | 3 (10.0%) | -6.67% (-19.18%, 5.84%) | 0.612 |
| Atropine requirement | 1 (3.3%) | 3 (10.0%) | -6.67% (-19.18%, 5.84%) | 0.612 |
| Episodes of Hypotension | 2.77 (2.10) | 4.17 (1.74) | -1.40 (-2.40, -0.40) | 0.007 |
| Mephentermine requirement (mg) | 15 (6–24) | 27 (18–30) | -6.90 (-12.31, -1.49) | 0.021 |
| Noradrenaline requirement (μg) | 0 (0-0) | 0 (0-390) | -74.00 (-374.43, 226.43) | 0.098 |
| Total Crystalloid infused (mL) | 2500 (2200–3725) | 2500 (2500–3000) | 73.33 (-367.28, 513.95) | 0.685 |
| Total Colloid infused (mL) | 0 (0-0) | 0 (0-500) | -158.33 (-268.91, -47.75) | 0.012 |
| Blood Loss (mL) | 300 (212.5-487.5) | 400 (322.5-595) | -24.67 (-196.12, 146. 79) | 0.047 |
| Urine output (mL) | 555 (400-600) | 425 (327.5-600) | -102.33 (-46.86, 251.53) | 0.240 |
Data are expressed in numbers (n), percentages (%), mean (standard deviation), or median (interquartile range). GA + TEA=General anaesthesia + thoracic epidural anaesthesia; TCSA=Thoracic continuous spinal anaesthesia; IQR=Interquartile range; T0=Preoperative; T1=1 hour postoperative; T2=Postoperative day 1; T3=Postoperative day 2; T4=Postoperative day 3
Postoperative outcomes were largely comparable between Group GA+TEA and Group TCSA. Group TCSA had a shorter time to first flatus (P = 0.010) and decreased pain at 1 h (P < 0.001) and POD1 (P = 0.002), indicating faster gastrointestinal recovery and superior early analgesia. PDPH occurred exclusively in Group TCSA (16.7%, P = 0.052) [Table 5]. No differences were reported in complications.
Table 5.
Postoperative events
| Parameter | Group GA + TEA (n=30) | Group TCSA (n=30) | Mean difference (95% CI) | P |
|---|---|---|---|---|
| PONV (n/%) | ||||
| T1 | 2 (6.7%) | 0 (0.0%) | 6.67% (-2.26%, 15.59%) | 0.492 |
| T2 | 3 (10.0%) | 8 (26.7%) | -16.67% (-35.79%, 2.46%) | 0.095 |
| T3 | 1 (3.3%) | 5 (16.7%) | -13.33% (-1.47%, 28.14%) | 0.195 |
| T4 | 0 (0.0%) | 0 (0.0%) | 0% (0%, 0%) | 1.000 |
| Postoperative ICU stay (days) | 0 (0–0) | 0 (0–0) | -0.03 (-0.23, 0.17) | 0.584 |
| Postoperative Hospital Stay (days) | 10.00 (7.00–13.00) | 8.50 (6.00 – 13.00) | 1.77 (-2.21, 5.74) | 0.272 |
| Time to Flatus (days) | 2 (2–3) | 2 (1–2) | 0.70 (0.16, 1.24) | 0.010 |
| Time to Oral Feeding (days) | 4 (2–5) | 3 (2–4) | 0.66 (-0.25, 1.58) | 0.305 |
| NRS for Pain | ||||
| T1 | 3.0 (2.0–5.0) | 0.0 (0.0–1.0] | 2.98 (2.38, 3.59) | <0.001 |
| T2 | 3.0 (2.0–3.0) | 2.0 (1.0–3.0) | 0.53 (-0.01, 1.07) | 0.002 |
| T3 | 2.0 (1.0–2.0) | 2.0 (1.0–2.0) | 0.30 (-0.16, 0.76) | 0.373 |
| T4 | 1.0 (1.0–2.0) | 1.0 (1.0–1.0) | 0.20 (-0.04, 0.44) | 0.078 |
| POMI (n/%) | 0 (0%) | 1 (3.3%) | 0% (-9.08%, 9.08%) | >0.99 |
| PDPH (n/%) | 0 (0%) | 5 (16.7%) | -16.67% (-30.00%, -3.33%) | 0.052 |
| Clavein-Dindo Grading | ||||
| Grade I | 22 (73.3%) | 19 (63.3%) | 10% (-13.40%, 33.40%) | 0.580 |
| Grade II | 6 (20.0%) | 9 (30.0%) | -10.00% (-31.77%, 11.77%) | 0.552 |
| Grade IIIa | 2 (6.7%) | 1 (3.3%) | 3.33% (-7.66%, 14.33%) | >0.99 |
| Grade IV | 0 (0%) | 1 (3.3%) | -3.33% (-9.76%, 3.09%) | >0.99 |
| In-hospital Mortality | 0 (0%) | 0 (0.0%) | 0% (0%, 0%) | >0.99 |
Data are expressed in numbers (percentage), and median (IQR). GA + TEA=General anesthesia + thoracic epidural anaesthesia; TCSA=Thoracic continuous spinal anesthesia; IQR=Interquartile; T1=1 hour postoperative; T2=Postoperative day 1; T3=Postoperative day 2; T4=Postoperative day 3; PONV=postoperative nausea and vomiting; ICU=intensive care unit; NRS=numerical rating scale; PDPH=postdural puncture headache; POMI=perioperative myocardial infrction
DISCUSSION
This study demonstrates that both anaesthesia techniques (GA+TEA and TCSA) were associated with significant reductions in PEFR, particularly at postoperative 1 h and day 1, consistent with known effects of diaphragmatic dysfunction, reduced functional residual capacity, and residual sedation.[9] The intergroup differences in PEFR were similar (P > 0.05), likely due to the application of lung-protective ventilation strategies and the excellent analgesic effect of TEA in Group GA+TEA.[5,6]
Conversely, the BHT was significantly greater in Group TCSA on day 1 (postoperative) (P = 0.044) and day 2 (P = 0.005), suggesting more rapid recovery of respiratory functions, likely due to preserved diaphragmatic function, reduced systemic opioid use, and improved thoracic wall compliance.[10,11] Although baseline SpO2 was marginally lower in Group TCSA (P = 0.030), postoperative values remained comparable between groups.
Atelectasis occurred significantly less frequently in Group TCSA at 1 hour postoperatively (10.0% vs. 36.7%; P = 0.030), reflecting better preservation of pulmonary mechanics. This may be attributed to avoidance of intubation, spontaneous ventilation, and reduced opioid-related respiratory depression.[10,12] Baseline ∆TDI was comparable between groups, but a significant postoperative decline was observed in Group GA+TEA, reflecting impaired diaphragmatic function. Group TCSA better preserved diaphragmatic excursion by avoiding intubation and mechanical ventilation. Though both groups improved over time, Group TCSA consistently showed higher ∆TDI values, suggesting faster diaphragmatic recovery.[10,12] Group TCSA also reported a substantially decreased pain score at 1 hour (P < 0.001) and POD 1 (P = 0.002), highlighting superior analgesia from TCSA.[13,14]
Group TCSA was associated with a higher frequency of intraoperative hypotensive episodes (P = 0.007), increased mephentermine requirements (P = 0.021), and greater colloid administration (P = 0.012), reflecting more pronounced sympathetic blockade associated with spinal anaesthesia that requires more frequent doses of inotropes and colloids to counter these side effects.[15] The blood loss was marginally but substantially higher among Group TCSA (P = 0.047), while urine output and noradrenaline use did not differ significantly.[16]
No neurological complications, such as nerve injury or persistent motor deficits, were observed in either group. Although transient paraesthesia was reported in 43.3% of TCSA patients, primarily during catheter insertion, all cases resolved without sequelae. This aligns with accumulating evidence supporting the safety of high thoracic neuraxial techniques when performed with appropriate technique and vigilance.[13,17,18]
Additionally, there were no in-hospital mortalities recorded among any participants. However, one of the participants of Group TCSA experienced a type-2 myocardial ischemia but recovered well and was discharged without complications. The absence of mortality and major adverse events, particularly in a population undergoing high-risk abdominal procedures, underscores the clinical safety of both GA+TEA and TCSA. Neuraxial techniques, including TCSA, have been associated with reduced perioperative morbidity and improved outcomes in high-risk patients due to their superior pain control and attenuated surgical stress response.[13,17,18,19]
TCSA demonstrated advantages in early postoperative pulmonary recovery and analgesia, with a risk of increased haemodynamic variability. With no observed increase in neurological complications or mortality, TCSA represents a practical substitute for GA+TEA, particularly in patients where preserving respiratory function and minimising anaesthetic drug exposure is desirable.
The current study had certain limitations, including an exploratory nature with limited participants, conducted at a single-centred design, which curbs its ability to generalise its outcomes. Also, the use of ultrasound for assessing lung parameters and functions may introduce operator-dependent variability.
CONCLUSION
Thoracic continuous spinal anaesthesia (TCSA) and general anaesthesia with thoracic epidural (GA+TEA) both resulted in comparable peak expiratory flow rate in the postoperative period; however, TCSA was associated with significantly better breath-holding time, reduced incidence of atelectasis, and superior postoperative analgesia. At the same time, TCSA demonstrated greater haemodynamic variability requiring increased vasopressor and colloid support without any neurological sequelae in patients undergoing major abdominal surgery.
Presentation at conferences/CMEs and abstract publication
Presented at the 42nd ESRA Annual Congress held in Oslo, Norway, from 10th to 13th September 2025.
Study data availability
De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors’ institution’s policy.
Disclosure of use of artificial intelligence (AI)-assistive or generative tools
The AI tools or language models (LLM) have not been utilised in the manuscript, except that software has been used for grammar corrections and references.
Declaration of use of permitted tools
The scales, scores, figures, and tables [Numerical rating Scale, Charlson Comorbidity Index, Assess Respiratory Risk in Surgical Patients in Catalonia, Clavien-Dindo Classification] are freely available and not copyrighted.
Authors contributions
GK was involved in data acquisition and manuscript preparation., PT was involved in concepts, design and conduct of cases, GJ was involved in concepts and data analysis, RT was involved in conduct of cases., AG was involved in the literature search, and NC was involved in the concept and design of the study.
Conflicts of interest
There are no conflicts of interest.
Supplementary material
None.
Acknowledgements
None.
Funding Statement
Nil.
REFERENCES
- 1.Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118:317–34. doi: 10.1093/bja/aex002. [DOI] [PubMed] [Google Scholar]
- 2.Abbott TEF, Fowler AJ, Pelosi P, Gama de Abreu M, Møller AM, Canet J, et al. A systematic review and consensus definitions for standardised end-points in perioperative medicine: Pulmonary complications. Br J Anaesth. 2018;120:1066–79. doi: 10.1016/j.bja.2018.02.007. [DOI] [PubMed] [Google Scholar]
- 3.Kelkar KV. Postoperative pulmonary complications after non-cardiothoracic surgery. Indian J Anaesth. 2015;59:599–605. doi: 10.4103/0019-5049.165857. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lusquinhos J, Tavares M, Abelha F. Postoperative pulmonary complications and perioperative strategies: A systematic review. Cureus. 2023;15:e38786. doi: 10.7759/cureus.38786. doi: 10.7759/cureus.38786. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Pirie KP, Wang A, Yu J, Teng B, Doane MA, Myles PS, et al. Postoperative analgesia for upper gastrointestinal surgery: A retrospective cohort analysis. Perioper Med (Lond) 2023;12:40. doi: 10.1186/s13741-023-00324-0. doi: 10.1186/s13741-023-00324-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Huang J. Enhanced recovery after surgery (ERAS) protocols and perioperative lung protection. J Anesth Perioper Med. 2014;1:50–6. [Google Scholar]
- 7.Saraogi A. Lung ultrasound: Present and future. Lung India. 2015;32:250–7. doi: 10.4103/0970-2113.156245. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Santana PV, Cardenas LZ, de Albuquerque ALP, de Carvalho CRR, Caruso P. Diaphragmatic ultrasound: A review of its methodological aspects and clinical uses. J Bras Pneumol. 2020;46:e20200064. doi: 10.36416/1806-3756/e20200064. doi: 10.36416/1806-3756/e20200064. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Garg S, Govindaraj V, Dwivedi DP, Raja K, Theerthar EP. Postoperative pulmonary complications in patients undergoing upper abdominal surgery: Risk factors and predictive models. Monaldi Arch Chest Dis. 2025:95. doi: 10.4081/monaldi.2024.2915. doi: 10.4081/monaldi. 2024.2915. [DOI] [PubMed] [Google Scholar]
- 10.van Zundert AA, Stultiens G, Jakimowicz JJ, Peek D, van der Ham WG, Korsten HH, et al. Laparoscopic cholecystectomy under segmental thoracic spinal anaesthesia: A feasibility study. Br J Anaesth. 2007;98:682–6. doi: 10.1093/bja/aem058. [DOI] [PubMed] [Google Scholar]
- 11.Naghibi K, Saryazdi H, Kashefi P, Rohani F. The comparison of spinal anesthesia with general anesthesia on the postoperative pain scores and analgesic requirements after elective lower abdominal surgery: A randomized, double-blinded study. J Res Med Sci. 2013;18:543–8. [PMC free article] [PubMed] [Google Scholar]
- 12.Imbelloni LE. Spinal anesthesia for laparoscopic cholecystectomy: Thoracic vs. Lumbar technique. Saudi J Anaesth. 2014;8:477–83. doi: 10.4103/1658-354X.140853. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Spannella F, Giulietti F, Damiani E, Faloia L, Stronati M, Venezia A, et al. Thoracic continuous spinal anesthesia for high-risk comorbid older patients undergoing major abdominal surgery: One-year experience of an Italian geriatric hospital. Minerva Anestesiol. 2020;86:261–9. doi: 10.23736/S0375-9393.19.13896-5. [DOI] [PubMed] [Google Scholar]
- 14.Pöpping DM, Elia N, Marret E, Remy C, Tramèr MR. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: A meta-analysis. Arch Surg. 2008;143:990–9. doi: 10.1001/archsurg.143.10.990. [DOI] [PubMed] [Google Scholar]
- 15.Alimian M, Mohseni M, Safaeian R, Faiz SHR, Majedi MA. Comparison of hydroxyethyl starch 6% and crystalloids for preloading in elective caesarean section under spinal anesthesia. Med Arch. 2014;68:279–81. doi: 10.5455/medarh.2014.68.279-281. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Wong RP, Carter HB, Wolfson A, Faustin C, Cohen SR, Wu CL. Use of spinal anesthesia does not reduce intraoperative blood loss. Urology. 2007;70:523–6. doi: 10.1016/j.urology.2007.04.034. [DOI] [PubMed] [Google Scholar]
- 17.Castellani D, Starnari R, Faloia L, Stronati M, Venezia A, Gasparri L, et al. Radical cystectomy in frail octogenarians in thoracic continuous spinal anesthesia and analgesia: A pilot study. Ther Adv Urol. 2018;10:343–9. doi: 10.1177/1756287218795427. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Vincenzi P, Starnari R, Faloia L, Grifoni R, Bucchianeri R, Chiodi L, et al. Continuous thoracic spinal anesthesia with local anesthetic plus midazolam and ketamine is superior to local anesthetic plus fentanyl in major abdominal surgery. Surg Open Sci. 2020;2:5–11. doi: 10.1016/j.sopen.2020.07.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Guay J, Choi P, Suresh S, Albert N, Kopp S, Pace NL. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: An overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 2014;2014:CD010108. doi: 10.1002/14651858.CD010108.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]