A Randomized Controlled Trial of Postoperative Thoracic Epidural Analgesia Versus Intravenous Patient-controlled Analgesia After Major Hepatopancreatobiliary Surgery

Abstract

Objectives The primary objective of this randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient controlled analgesia (IV-PCA) for pain control over the first 48 hours after hepatopancreatobiliary (HPB) surgery. Secondary endpoints were patient-reported outcomes, total narcotic utilization and complications. Summary of Background Data Although adequate postoperative pain control is critical to patient and surgeon success, the optimal analgesia regimen in HPB surgery remains controversial. Methods Using a 2.5:1 randomization strategy, 140 patients were randomized to TEA (N=106) or IV-PCA (N=34). Patient-reported pain was measured on a Likert scale (0–10) at standard time intervals. Cumulative pain area under the curve (AUC) was determined using the trapezoidal method. Results Between the study groups key demographic, comorbidity, clinical and operative variables were equivalently distributed. The median AUC of the postoperative time 0 to 48 hour pain scores was lower in the TEA group (78.6 vs 105.2 pain-hours, p=0.032) with a 35% reduction in patients experiencing ≥7/10 pain (43% vs 66%, p=0.05). Patient-reported outcomes and total opiate use further supported the benefit of TEA on patient experience. Anesthesia related events requiring change in analgesic therapy were comparable (12.2% vs. 2.9%, respectively, p=0.187). Grade ≥3 surgical complications, median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the OR (0.9 vs 3.1%) were similar (all p>0.05). There were no mortalities in either group. Conclusions In major HPB surgery, TEA provides a superior patient experience through improved pain control and less narcotic use, without increased length of stay or complications.

Meta‐analysis of epidural analgesia in patients undergoing pancreatoduodenectomy

“…Fewer complications occurred following EA treatment than with intravenous morphine in the present analysis, in contrast to findings in previous studies 33,34,36,37 . Here, only one study 22 (EA versus intravenous morphine) reported significantly fewer complications with EA, the difference remaining significant after adjustment for several factors.…”

“…It is notable that only two studies 21,23 used patient-controlled EA, despite evidence that this technique is associated with improved pain scores, patient satisfaction and safety parameters 31,32 . Nevertheless, in concordance with recent RCTs in major abdominal surgery, EA has marginal beneficial effects on pain scores during the early postoperative period compared with intravenous morphine 33,34 .…”

A Literature Review of Intrathecal Morphine Analgesia in Patients Undergoing Major Open Hepato-Pancreatic-Biliary (HPB) Surgery

“…However a randomised controlled trial by Aloia et al found that hypotension can be minimised in the context of epidural anaesthesia use in major open hepatobiliary surgery via administration of lower-than-standard concentration of local anaesthetic (0.075% bupivacaine), and implementation of a regimented rescue bolus schedule (41). In summary, epidural analgesia is associated with a risk of postoperative hypotension and hence fluid overload that is not present with intrathecal analgesia, but this risk can be mitigated with adherence to the correct protocol.…”

Ultrasound Guided Continuous Quadratus Lumborum Block Hastened Recovery in Patients Undergoing Open Liver Resection: A Randomized Controlled, Open-label Trial

“…Although laparoscopic liver resection has been used in clinical practice, it is still in the developing stage, and open surgery is a more commonly used surgical method [1,2]. An open liver resection requires a long incision which is traumatic, it is often associated with severe postoperative pain, mainly due to transection and traction on multiple spinal nerves [3,4]. Postoperative pain causes not only psychological trauma but also increases the incidence of perioperative complications.…”