First initiation of mobilization out of bed after cardiac surgery - an observational cross-sectional study in Sweden.

BACKGROUND: Cardiac surgery is associated with a period of postoperative bed rest. Although early mobilization is a vital component of postoperative care, for preventing complications and enhancing physical recovery, there is limited data on routine practices and optimal strategies for early mobilization after cardiac surgery. The aim of the study was to define the timing for the first initiation of out of bed mobilization after cardiac surgery and to describe the type of mobilization performed. METHODS: In this observational study, the first mobilization out of bed was studied in a subset of adult cardiac surgery patients (n = 290) from five of the eight university hospitals performing cardiothoracic surgery in Sweden. Over a five-week period, patients were evaluated for mobilization routines within the initial 24 h after cardiac surgery. Data on the timing of the first mobilization after the end of surgery, as well as the duration and type of mobilization, were documented. Additionally, information on patient characteristics, anesthesia, and surgery was collected. RESULTS: A total of 277 patients (96%) were mobilized out of bed within the first 24 h, and 39% of these patients were mobilized within 6 h after surgery. The time to first mobilization after the end of surgery was 8.7 ± 5.5 h; median of 7.1 [4.5-13.1] hours, with no significant differences between coronary artery bypass grafting, valve surgery, aortic surgery or other procedures (p = 0.156). First mobilization session lasted 20 ± 41 min with median of 10 [1-11]. Various kinds of first-time mobilization, including sitting on the edge of the bed, standing, and sitting in a chair, were revealed. A moderate association was found between longer intubation time and later first mobilization (ρ = 0.487, p < 0.001). Additionally, there was a moderate correlation between the first timing of mobilization duration of the first mobilization session (ρ = 0.315, p < 0.001). CONCLUSIONS: This study demonstrates a median time to first mobilization out of bed of 7 h after cardiac surgery. A moderate correlation was observed between earlier timing of mobilization and shorter duration of the mobilization session. Future research should explore reasons for delayed mobilization and investigate whether earlier mobilization correlates with clinical benefits. TRIAL REGISTRATION: FoU in VGR (Id 275,357) and Clinical Trials (NCT04729634).

Development of and adherence to an ERAS® and prehabilitation protocol for patients undergoing pancreatic surgery: An observational study.

BACKGROUND AND OBJECTIVE: There are still gaps in knowledge concerning the adherence to different multimodal pathways in pancreatic surgery. The aim of this trial was to explore and evaluate an Enhanced Recovery After Surgery (ERAS®) and prehabilitation protocol in patients undergoing open pancreatic surgery. METHODS: Three groups of patients were included: two prospective series of 75 patients undergoing open pancreatic surgery following an ERAS® protocol with or without prehabilitation, and one group of 55 historical controls. Variables regarding adherence to, and effects of the protocols, were collected from the local database and the patients' hospital records. Patients' adherence to advice given pre-operatively was followed up using a study-specific questionnaire. RESULTS: The patients reported high adherence to remembered advice given. The health care professionals' adherence to the various parts of the concepts varied. ERAS® implementation resulted in more frequent gut motility stimulation (p < 0.001) and shorter duration of epidural anesthesia, site drains, and urinary catheter (p = 0.001). With prehabilitation, more patients were screened concerning nutritional status and prescribed preoperative training (p < 001). There was a significant change in weight before surgery, a shorter time to first flatus and a shorter length of stay after implementation of the concepts (p < 0.05). Complications were rare in all three groups and there were no significant differences between the groups. CONCLUSION: The implementation of an ERAS® and a prehabilitation protocol increased adherence to the protocols by both patients and healthcare professionals. An implementation of an ERAS® protocol with and without prehabilitation decreases length of stay and may decrease preoperative weight loss and time to bowel movement.

Physical Therapy Treatment of Impaired Chest Mobility in Patients with Airway Sensory Hyperreactivity.

BACKGROUND AND PURPOSE: In sensory hyperreactivity (SHR), patients have symptoms from the airways and the chest induced by environmental irritants like scenting products and cigarette smoke. They are characterized by increased cough reaction to inhaled capsaicin compared with healthy controls. Lung function tests are normal, and asthma medications have no or little effect. In a recent published article, patients with SHR were found to have impaired chest mobility and increased pain sensitivity. The purpose of this study was to evaluate if a physiotherapeutic intervention can increase chest mobility in SHR, influence these patients' symptoms and reduce capsaicin cough sensitivity. METHODS: Forty-one SHR patients were initially randomized in to groups, one for training and one for symptom registration in this controlled training study. It consisted of a daily training programme containing simple movements to increase the flexibility of the chest, a breathing exercise and a relaxation session as well as symptom registration. Chest expansion was measured with a measuring tape and thoracic and abdominal movement with light sensors. Pain sensitivity was assessed using pressure algometry and a standardized capsaicin inhalation threshold provocation-evaluated cough sensitivity. RESULTS: Twenty seven patients were left for analyses after 12 weeks and 26 patients after 24 weeks. Chest mobility and upper thoracic respiratory movements improved (p < 0.01), feeling of chest pressure and the capsaicin cough sensitivity decreased (p < 0.01). The patients also showed of significantly lowered pain pressure thresholds measured with algometry, compared with healthy controls (p < 0.001). CONCLUSION: Improvement of chest mobility after physiotherapeutic intervention indicates that these patients may have acquired a dysfunctional breathing pattern. The regular use of a training programme and structural breathing instructions can be used to improve chest mobility, chest symptoms and capsaicin cough sensitivity in patients with SHR and signs of dysfunctional breathing. Copyright © 2016 John Wiley & Sons, Ltd.

Evaluation of excess skin in Swedish adults 18-59 years of age.

BACKGROUND: Little is known about excess skin in the normal population. The aim of this study was, therefore, to analyse the prevalence, impairments, and discomfort of excess skin in a cross-section of the Swedish population. METHODS: From the population registry of the Swedish Tax Agency, 1408 subjects living in Västra Götaland County from 18-59 years of age were randomly selected with an equal distribution of the sexes. Additionally, age was equally distributed, although twice as many subjects under 40 years of age were sent the questionnaire due to an expected low response rate for younger people. All subjects were asked to fill out the Sahlgrenska Excess Skin Questionnaire (SESQ), which included questions concerning the amount of and discomfort due to excess skin. RESULTS: No excess skin was reported by 78% of responders, including 71% of women and 87% of men. The responders who reported any excess skin were significantly older, had a higher body mass index (BMI) and reported larger differences between their maximum and current BMI. The most common reported site of excess skin was the abdomen in both women and men (26% and 8%, respectively), and this was reported to cause the most discomfort (median 4 and 2, respectively, on a scale from 0-10). Women graded psychosocial symptoms significantly higher than men, but there were no significant differences in other symptoms. CONCLUSIONS: The results indicate that Swedish adults, regardless of sex, do not suffer from excess skin and may be considered as reference values.

Understanding excess skin in postbariatric patients: objective measurements and subjective experiences.

BACKGROUND: Excess skin is a well-known side effect of massive weight loss after bariatric surgery. However, there is a lack of longitudinal follow-ups. OBJECTIVES: The primary aims of this study were to investigate the development and amount of excess skin after laparoscopic Roux-en-Y gastric bypass and to relate objective results to subjective experiences. SETTING: University hospital. METHODS: From 2009 to 2012, 200 patients were included and assessed with respect to excess skin before and 18 months after bariatric surgery. Patients were measured according to a standardized protocol and completed a questionnaire regarding their subjective experience of excess skin. RESULTS: A follow-up visit was completed in 149 patients (78%). All ptosis measurements decreased after weight reduction except for ptosis on the thighs. When comparing objective measurements with patients' subjective experience and discomfort from excess skin, we found little or low correlation in most body parts (rs .03-.67). The prediction analysis indicated that, for every centimeter of ptosis on the abdomen preoperatively, there was a 2-fold greater probability of having a postoperative ptosis on the abdomen of>3 cm (OR = 2.32, 1.76-3.07). CONCLUSION: The objective measurement of excess skin provides unique information in postbariatric patients' body habitus. Although the measured excess skin decreased compared with preoperative measurements, patients seem to become more aware of and disturbed and discomforted by it after the weight loss. Importantly, the objectively assessed measurements of excess skin correlated fairly with the perceived discomfort.

The Effect of Abdominoplasty and Outcome of Rectus Fascia Plication on Health-Related Quality of Life in Post-Bariatric Surgery Patients.

BACKGROUND: The authors prospectively evaluated the effect of isolated abdominoplasty with or without rectus fascia plication on the physical, functional, and psychosocial dimensions of health-related quality of life in post-bariatric surgery patients. They also evaluated whether the objectively measured amount of abdominal excess skin affects the discomfort of excess abdominal skin and changes in health-related quality of life after abdominoplasty. METHODS: Ninety-four post-bariatric surgery patients answered questionnaires regarding their experience of excess skin and health-related quality of life before and 1 year after isolated abdominoplasty. An objective assessment of the amount of abdominal excess skin was also performed. All study participants were assigned randomly to either undergo or not undergo rectus fascia plication. RESULTS: Significant improvements were reported at the follow-up concerning physical, functional, and psychosocial dimensions of health-related quality of life. A significant decrease was observed for the general health subscale of the 36-Item Short-Form Health Survey for the nonplicated group (p = 0.039). No significant differences were observed between the plicated and nonplicated groups. A significant low correlation was identified between the change in the Short-Form physical function subscale after abdominoplasty and measured amount of excess abdominal skin (rs = 0.26, p = 0.033) or resection weight (rs = 0.20, p = 0.10). CONCLUSIONS: Isolated abdominoplasty in post-bariatric surgery patients seems to improve both physical and psychosocial dimensions of health-related quality of life. However, rectus fascia plication does not appear to influence health-related quality of life. In addition, the correlation between the objectively measured amount of abdominal excess skin and improvements in health-related quality of life after abdominoplasty in post-bariatric surgery patients appears to be low.

Effects of chewing gum against postoperative ileus after pancreaticoduodenectomy--a randomized controlled trial.

BACKGROUND: Postoperative ileus is common after surgery. One non-pharmacological intervention that has shown promising results in reducing the duration of postoperative ileus is chewing gum after surgery. However, this has not been investigated in upper gastrointestinal surgery such as pancreatic surgery. Hence the aim of this study was to investigate the effects of chewing gum treatment on patients undergoing pancreaticoduodenectomy ad modum whipple due to pancreatic or periampullary cancer. METHODS: This study was conducted as a phase III trial that was terminated early. Patients diagnosed with pancreatic tumours scheduled for pancreaticoduodenectomy ad modum whipple were included. The treatment group received chewing gum postoperatively and standard care. Controls received glucose solution and standard care. Chewing gum and glucose were used four times a day during the whole hospital stay. Time to first flatus and stool was defined as the primary outcome. The secondary outcome was start with clear liquids, start with liquid diet and length of hospital stay. RESULTS: No statistically significant differences could be observed between the chewing gum intervention group and the control group. However, a numerical difference in mean time was observed in first flatus, first stool, start of clear fluids, and start of liquid diet and length of hospital stay in favour of the intervention group. CONCLUSIONS: Although this study did not find statistically significant differences favouring the use of chewing gum for postoperative ileus, a positive trend was observed of a reduction of the impact of postoperative ileus among patients after pancreatic surgery. It also contributes valuable methodological experience that is important for future studies of chewing gum interventions during recovery after pancreatic surgery. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02319512 , publication date 2014-12-17.

Five-year outcomes after laparoscopic gastric bypass and laparoscopic duodenal switch in patients with body mass index of 50 to 60: a randomized clinical trial.

IMPORTANCE: There is no consensus as to which bariatric procedure is preferred to reduce weight and improve health in patients with a body mass index higher than 50. OBJECTIVE: To compare 5-year outcomes after Roux-en-Y gastric bypass (gastric bypass) and biliopancreatic diversion with duodenal switch (duodenal switch). DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical open-label trial at Oslo University Hospital, Oslo, Norway, and Sahlgrenska University Hospital, Gothenburg, Sweden. Participants were recruited between March 17, 2006, and August 20, 2007, and included 60 patients aged 20 to 50 years with a body mass index of 50 to 60. The current study provides the 5-year follow-up analyses by intent to treat, excluding one participant accepted for inclusion who declined being operated on prior to knowing to what group he was randomized. INTERVENTIONS: Laparoscopic gastric bypass and laparoscopic duodenal switch. MAIN OUTCOMES AND MEASURES: Body mass index and secondary outcomes including anthropometric measures, cardiometabolic risk factors, pulmonary function, vitamin status, gastrointestinal symptoms, health-related quality of life, and adverse events. RESULTS: Sixty patients were randomly assigned and operated on with gastric bypass (n = 31) and duodenal switch (n = 29). Fifty-five patients (92%) completed the study. Five years after surgery, the mean reductions in body mass index were 13.6 (95% CI, 11.0-16.1) and 22.1 (95% CI, 19.5-24.7) after gastric bypass and duodenal switch, respectively. The mean between-group difference was 8.5 (95% CI, 4.9-12.2; P < .001). Remission rates of type 2 diabetes mellitus and metabolic syndrome and changes in blood pressure and lung function were similar between groups. Reductions in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting glucose were significantly greater after duodenal switch compared with gastric bypass. Serum concentrations of vitamin A and 25-hydroxyvitamin D were significantly reduced after duodenal switch compared with gastric bypass. Duodenal switch was associated with more gastrointestinal adverse effects. Health-related quality of life was similar between groups. Patients with duodenal switch underwent more surgical procedures related to the initial procedure (13 [44.8%] vs 3 [9.7%] patients; P = .002) and had significantly more hospital admissions compared with patients with gastric bypass. CONCLUSIONS AND RELEVANCE: In patients with a body mass index of 50 to 60, duodenal switch resulted in greater weight loss and greater improvements in low-density lipoprotein cholesterol, triglyceride, and glucose levels 5 years after surgery compared with gastric bypass while improvements in health-related quality of life were similar. However, duodenal switch was associated with more surgical, nutritional, and gastrointestinal adverse effects. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00327912.

Experience of excess skin after gastric bypass or duodenal switch in patients with super obesity.

BACKGROUND: There is a lack of knowledge about the patient's experience of excess skin after bariatric surgery in patients with body mass index, (BMI)>50 kg/m(2). The objective of this study was to evaluate experience of excess skin after laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) or laparoscopic Roux-en-Y gastric bypass (LRYGB) and explore possible gender differences. Another aim was to analyze possible correlation between the reported experiences of excess skin with changes in weight, BMI, and hip and waist circumference after surgery. METHODS: One and/or 2 years after gastric bypass or duodenal switch surgery 57 patients responded to a specific questionnaire. The questionnaire included questions about the amount of excess skin and how much discomfort it caused. Furthermore, the patients were measured concerning weight and waist and hip circumference. RESULTS: One year after surgery, a majority of the patients experienced excess skin scored as>2 ("a lot of" or "very much"). The patients in the BPD/DS group experienced significantly more excess skin compared to patients in the LRYGB group. Women experienced more excess skin and discomfort on several body parts than men. The correlations between changes in BMI and the reported experience and discomfort of excess skin were low. There was a low to moderate correlation between changes in waist and hip circumference measures and the experience of excess skin on stomach and buttocks. CONCLUSION: Weight loss after LRYGB and BPD/DS in super-obese patients is associated with substantial discomfort from excess skin. Women reported more discomfort and experienced more excess skin than men. There was a low correlation between experience of excess skin and changes in weight, BMI, and circumference measures.

Sahlgrenska Excess Skin Questionnaire (SESQ): a reliable questionnaire to assess the experience of excessive skin after weight loss.

There is a lack of knowledge and reliable measurement instruments to assess excess skin after massive weight loss. The purpose of this study was to test the reliability of a new self-administered questionnaire. A self-administered questionnaire, the Sahlgrenska Excess Skin Questionnaire (SESQ) was designed to assess excess skin after weight loss. The questionnaire includes 30 questions about demographic data, activity and daily life and excess skin on specific body parts and the body as a whole. Forward and backward translations were made by two independent professional translators, from Swedish to English and then back to Swedish. The questionnaire was tested on 10 patients from Sweden and England and was followed by an interview with each patient. Minor corrections were made. A test-retest was carried out to evaluate the reliability by sending the Swedish questionnaire to 46 subjects with weight loss after obesity surgery, dieting, or medication. The test-retest reliability of questions concerning activity and daily life between the two occasions had a Percentage Of Agreement (POA) of 49%-76% and a weighted Kappa of 0.44-0.78. The questions about the degree of excess skin on specific body parts had a POA of 50%-76% and a weighted Kappa of 0.53-0.81. Excess skin perceived as causing problems had a POA of 32%-57 %, an adjusted POA of 63%-87%, and an Intra-Class Correlation of 0.72-0.92. The SESQ is reliable for evaluating patients' experience of excess skin after massive weight loss.

Complications of abdominoplasty after weight loss as a result of bariatric surgery or dieting/postpregnancy.

It is well known that the risk of complications after abdominal contouring surgery is high. Sparse data in published reports exist, suggesting that complication rates are higher in postbariatric patients compared with patients who have lost weight by dieting. The aim of this study was to analyse the incidence of complications after abdominoplasty in postbariatric patients compared with in patients who have not had weight loss surgery. The aim was also to identify predictive factors associated with the development of postoperative complications. This study retrospectively analysed 190 consecutive patients operated on with abdominoplasty due to abdominal tissue excess from January 2006 to December 2008 at Sahlgrenska University Hospital. Variables analysed were sex, age, max body mass index (BMI), delta BMI (max BMI minus preoperative BMI), preoperative BMI, method of weight reduction, resection weight, and complications. The early complication rates were significantly higher in postbariatric patients (48%) than in patients who had not had weight loss surgery (29%). Resection weight was significantly higher for patients with early local complications compared with patients without early local complications. Max BMI, delta BMI, or preoperative BMI had no influence on the incidence of complications. In conclusion, this study confirms in a fairly large sample that the complication rate after abdominoplasty seems to be higher in postbariatric patients compared with patients who have not had weight loss surgery. However, no predictive factors could be identified explaining these differences. Further studies need to be conducted to identify predictive factors for the occurrence of complications after abdominal contouring surgery.

Fast-track concepts in major open upper abdominal and thoracoabdominal surgery: a review.

INTRODUCTION: The purpose of this article was to review the research considering fast-track concepts in upper abdominal and thoracoabdominal surgery. METHODS: A search for clinical studies evaluating the fast-track concept after open major upper abdominal or thoracoabdominal surgery was performed. Reference lists of identified articles were searched. Trials-written in English-that compared a concept and traditional care were evaluated with regard to their internal validity. Level of evidence was defined and each outcome was evaluated. RESULTS: In total, 15 articles were found, separated into gastric (n = 2), pancreatic (n = 5), hepatic (n = 2), esophageal (n = 3), and aortic surgery (n = 3). Three were randomized, controlled trials. The different trials represented various concepts of fast-track surgery, but the majority included specific programs for analgesics, avoidance of drainage tubes, early start of oral nutrition, and early and active mobilization. There is moderate evidence that fast-track concepts result in shorter hospital stay. There is low evidence that fast-track concepts shorten need of ventilation, decrease the need of care at the intensive care unit, decrease postoperative pain, and reduce total hospital costs. The concepts seem to have similar rates of surgical complications, readmission rate, and mortality rates as conventional care. No specific adverse events were reported. CONCLUSIONS: Although the methodological quality of the articles reviewed was low and the trials heterogeneous, all trials concluded that the introduction of fast-track concepts were safe and feasible, achieved shorter hospital stays, and reduced costs. Future randomized, controlled trials are needed to further evaluate the effect of these concepts.

The meaning of awaiting bariatric surgery due to morbid obesity.

BACKGROUND: The understanding of the association between the objective conditions of health and the subjective perceptions of morbidly obese patients appears to be poor. The use of objective indicators alone produces results totally unrelated to the feelings and experiences of the bariatric patients studied. No study has approached the bariatric patient from both an inside and a preoperative perspective. PURPOSE: The aim of this study was to investigate the meaning of awaiting bariatric surgery due to morbid obesity. METHOD: Twenty-three patients admitted to a Swedish University Hospital for bariatric surgery were included. Data were collected by interviews and the analysis was performed using the phenomenological hermeneutics method developed by Lindseth and Norberg. MAIN FINDINGS: Two structural thematic analyses revealed six main themes: experiencing food as a complex element in life, feeling hopeless regarding weight loss, living in fear of future sickness and death, living a restricted life, being ignored by health care professionals and hoping for control and opportunities. The informants experienced addiction to food and dependence on others for managing their daily life, which constituted an infringement of their freedom. Loss of control meant giving in to the desire for food, but also being subjected to stigmatizing remarks from persons in their environment or uncaring approaches from health care professionals. CONCLUSION: Being scheduled for bariatric surgery meant developing an awareness of how completely dependent they were on surgery for their survival and prospective health. The scheduled bariatric surgery constituted tangible confirmation that weight loss and restored health were possible.

Physical activity as viewed by adults with severe obesity, awaiting gastric bypass surgery.

BACKGROUND AND PURPOSE: Today, it is known that adults suffering from obesity benefit from physical activity. There is however lack of research with regard to how patients with severe obesity experience physical activity. It is important to explore this topic in order to be able to improve communication with and to tailor information and exercise programmes for patients suffering with obesity. The aim of the present qualitative study was to describe how adults with severe obesity, awaiting gastric bypass surgery experience physical activity. METHODS: A qualitative method inspired by a phenomenographic approach was used to analyze the data. Data collection was performed by in-depth semi-structured interviews with 18 patients. All patients were aged between 18 and 65 years, suffered from severe obesity and were scheduled for laparoscopic Roux-en Y gastric bypass surgery at Sahlgrenska University Hospital in Sweden. RESULTS: The analysis resulted in nine qualitatively different categories that were then divided into four aspects: 'the obese body', 'the mind', 'knowledge' and 'the environment'. Many patients experienced well-being after physical activity, but most patients were uncomfortable with appearing in public wearing exercise clothing. The excess weight itself was considered an obstacle, and weight loss was assumed to facilitate physical activity. Exercising together with someone at the same level of fitness increased motivation. A white lie about training was sometimes used to satisfy the need to be seen as capable. CONCLUSION: Physical activity is experienced positively among adults with severe obesity, but many obstacles exist that influence their capacity and their will. Support is necessary in different ways, not only to initiate physical activity, but also to maintain it.

Procedure-related chronic pain after thoracoabdominal resection of the esophagus.

Persistent pain after thoracoabdominal esophageal resection is basically unexplored. The aims of the study were to define the character, intensity, and duration of pain with onset following thoracoabdominal esophageal resection and whether this pain syndrome depended on the time elapsed since the operation, the patient's physical function, and level of activity. A questionnaire was constructed that included questions about pain before surgery and at the time of the follow-up as well as the patients' physical function and activity level. The questionnaire was sent to 51 long-term survivors of thoracoabdominal esophageal resection and 46 patients responded. At the follow-up, 20 of the 46 patients had pain in the right shoulder, 17 in the left shoulder, 24 in the rib cage, and 23 in the neck/upper back. Six patients reported severe pain (VAS > 60 mm) in the rib cage. A significantly larger proportion of patients had pain after surgery than before (p < 0.001). No correlation was observed between pain and the time elapsed since surgery, nor was pain related to physical function and activity level (r(s) = 0.120-0.350). Approximately half of the patients who had undergone thoracoabdominal esophageal resection suffered from procedure-related chronic pain. These results indicate the need for focused therapeutic interventions.

Thoracic epidural versus intravenous patient-controlled analgesia after cardiac surgery: a randomized controlled trial on length of hospital stay and patient-perceived quality of recovery.

BACKGROUND: Perioperative thoracic epidural analgesia reduces stress response and pain scores and may improve outcome after cardiac surgery. This prospective, randomized trial was designed to compare the effectiveness of patient-controlled thoracic epidural analgesia with patient-controlled analgesia with intravenous morphine on postoperative hospital length of stay and patients' perception of their quality of recovery after cardiac surgery. METHODS: One hundred thirteen patients undergoing elective cardiac surgery were randomly assigned to receive either combined thoracic epidural analgesia and general anesthesia followed by patient-controlled thoracic epidural analgesia or general anesthesia followed by to patient-controlled analgesia with intravenous morphine. Postoperative length of stay, time to eligibility for hospital discharge, pain and sedation scores, degree of ambulation, lung volumes, and organ morbidities were evaluated. A validated quality of recovery score was used to measure postoperative health status. RESULTS: Length of stay and time to eligibility for hospital discharge were similar between the groups. Study groups differed neither in postoperative global quality of recovery score nor in five dimensions of quality of recovery score. Time to extubation was shorter (P < 0.001) and consumption of anesthetics was lower in the patient-controlled thoracic epidural analgesia group. Pain relief, degree of sedation, ambulation, and lung volumes were similar between the study groups. There was a trend for lower incidences of pneumonia (P = 0.085) and confusion (P = 0.10) in the patient-controlled thoracic epidural analgesia group, whereas cardiac, renal, and neurologic outcomes were similar between the groups. CONCLUSIONS: In elective cardiac surgery, thoracic epidural analgesia combined with general anesthesia followed by patient-controlled thoracic epidural analgesia offers no major advantage with respect to hospital length of stay, quality of recovery, or morbidity when compared with general anesthesia alone followed by to patient-controlled analgesia with intravenous morphine.