Challenging epidural analgesia as the preferred route for postoperative analgesia in liver surgery

Here is my highlight from the July issue of HPB.

Good post-operative pain control is a central part of recovery after surgery. ERAS programmes, in particular, have heavily promoted the use of epidural analgesia for abdominal surgery. This probably owes something to the roots of ERAS in colorectal surgery however many of the studies on which these recommendations were made are outdated and relate to very different operative procedures. Epidural analgesia is known to offer good dynamic and static pain control but does have drawbacks in terms of hypotension, immobility and rare but life threatening complications of epidural abscess or epidural haematoma. The liver surgery group in Basingstoke have been one of the major centres pioneering local anaesthetic wound catheter infiltration of upper abdominal wounds combined with patient controlled opiates as an alternative to epidural analgesia. In this edition of HPB, Wong-Lu-Hing and colleagues report the Basingstoke experience of wound catheter analgesia after liver resection in a retrospective comparative cohort analysis including a small group of contemporaneous patients receiving epidural analgesia (analgesic selection based on surgeon preference). Although not a randomized trial they clearly show some important benefits from wound catheter analgesia. These were equivalency of analgesia combined with reduced overall complication rates, reduced opiate requirement and a shorter length of stay compared with patients receiving epidural analgesia. Further refinements to local anaesthetic protocols such as additional transversus abdominis plane blocks may improve the effectiveness of this analgesic approach and it seems certain that this will remain an effective alternative if not a preferred alternative to epidural analgesia in liver surgery.

SINGLE-USE-EPIDURAL-NEEDLE

Postoperative pain control using continuous i.m. bupivacaine infusion plus patient-controlled analgesia compared with epidural analgesia after major hepatectomy (pages 601–609)
Edgar M. Wong-Lun-Hing, Ronald M. van Dam, Fenella K. S. Welsh, John K. G. Wells, Timothy G. John, Adrian B. Cresswell, Cornelis H. C. Dejong and Myrddin Rees
Article first published online: 23 OCT 2013 | DOI: 10.1111/hpb.12183

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