From pain relief to organ protection: epidural analgesia in acute pancreatitis-a narrative review of its evolving role

Abstract

Background: Acute pancreatitis (AP) is a potentially life-threatening inflammatory condition with a wide clinical spectrum. In severe acute pancreatitis (SAP), impaired pancreatic microcirculation contributes to necrosis and multiorgan dysfunction. Despite advances in supportive care, therapeutic strategies that directly target pancreatic perfusion remain limited.

Objectives: This narrative review explores the evolving role of epidural analgesia (EA) in SAP, examining its physiological basis, experimental evidence, and clinical outcomes.

Methods: Literature was reviewed on the pathophysiology of pancreatitis, pancreatic microcirculation, and the use of EA in both animal models and human trials. Data from randomized controlled trials, meta-analyses, and cohort studies were synthesized.

Results: EA exerts beneficial effects by blocking thoracic sympathetic outflow, thereby improving splanchnic vasodilation and pancreatic perfusion. Animal studies demonstrated enhanced microcirculatory flow, reduced necrosis, and improved survival. Early clinical studies showed EA reduced enzyme levels, improved pain scores, and enhanced organ function. A recent systematic review and meta-analysis found EA to be safe, associated with reduced mortality and ventilatory requirements. However, the EPIPAN trial, a multicenter RCT, found no significant benefit in ventilator-free days and noted a longer duration of mechanical ventilation in EA recipients.

Conclusions: EA appears to be a safe adjunct modality in SAP management, offering analgesia and potential organ-protective effects. However, heterogeneity in study designs and outcomes necessitates larger, high-quality trials to clarify its role in routine practice.

Keywords: Acute pancreatitis; EPIPAN trial; Epidural analgesia; Organ failure; Pancreatic perfusion; Splanchnic circulation.