Role of epidural anesthesia in a fast track liver resection protocol for cirrhotic patients - results after three years of practice

Enhanced recovery after liver surgery in cirrhotic patients: a systematic review and meta-analysis

BACKGROUND

Few studies have assessed enhanced recovery after surgery (ERAS) in liver surgery for cirrhotic patients. The present meta-analysis assessed the impact of ERAS pathways on outcomes after liver surgery in cirrhotic patients compared to standard care.

METHODS

A literature search was performed on PubMed/MEDLINE, Embase, and the Cochrane Library. Studies comparing ERAS protocols versus standard care in cirrhotic patients undergoing liver surgery were included. The primary outcome was post-operative complications, while secondary outcomes were mortality rates, length of stay (LoS), readmissions, reoperations, and liver failure rates.

RESULTS

After evaluating 41 full-text manuscripts, 5 articles totaling 646 patients were included (327 patients in the ERAS group and 319 in the non-ERAS group). Compared to non-ERAS care, ERAS patients had less risk of developing overall complications (OR 0.43, 95% CI 0.31-0.61, p < 0.001). Hospitalization was on average 2 days shorter for the ERAS group (mean difference - 2.04, 95% CI - 3.19 to - 0.89, p < 0.001). Finally, no difference was found between both groups concerning 90-day post-operative mortality and rates of reoperations, readmissions, and liver failure.

CONCLUSION

In cirrhotic patients, ERAS protocol for liver surgery is safe and decreases post-operative complications and LoS. More randomized controlled trials are needed to confirm the results of the present analysis.

Effect of thoracic epidural anesthesia on postoperative outcome in major liver surgery: a retrospective cohort study

PURPOSE

Postoperative complications after major liver surgery are common. Thoracic epidural anesthesia may provide beneficial effects on postoperative outcome. We strove to compare postoperative outcomes in major liver surgery patients with and without thoracic epidural anesthesia.

METHODS

This was a retrospective cohort study in a single university medical center. Patients undergoing elective major liver surgery between April 2012 and December 2016 were eligible for inclusion. We divided patients into two groups according to whether or not they had thoracic epidural anesthesia for major liver surgery. The primary outcome was postoperative hospital length of stay, i.e., from day of surgery until hospital discharge. Secondary outcomes included 30-day postoperative mortality and major postoperative complications. Additionally, we investigated the effect of thoracic epidural anesthesia on perioperative analgesia doses and the safety of thoracic epidural anesthesia.

RESULTS

Of 328 patients included in this study, 177 (54.3%) received thoracic epidural anesthesia. There were no clinically important differences in postoperative hospital length of stay (11.0 [7.00-17.0] vs. 9.00 [7.00-14.0] days, p = 0.316, primary outcome), death (0.0 vs. 2.7%, p = 0.995), or the incidence of postoperative renal failure (0.6 vs. 0.0%, p = 0.99), sepsis (0.0 vs. 1.3%, p = 0.21), or pulmonary embolism (0.6 vs. 1.4%, p = 0.59) between patients with or without thoracic epidural anesthesia. Perioperative analgesia doses - including the intraoperative sufentanil dose (0.228 [0.170-0.332] vs. 0.405 [0.315-0.565] μg·kg-1·h-1, p < 0.0001) - were lower in patients with thoracic epidural anesthesia. No major thoracic epidural anesthesia-associated infections or bleedings occurred.

CONCLUSION

This retrospective analysis suggests that thoracic epidural anesthesia does not reduce postoperative hospital length of stay in patients undergoing major liver surgery - but it may reduce perioperative analgesia doses. Thoracic epidural anesthesia was safe in this cohort of patients undergoing major liver surgery. These findings need to be confirmed in robust clinical trials.

Efficacy of local anaesthetic infiltration via wound catheters after open hepatic surgery: a systematic review and meta-analysis

BACKGROUND

This study analysed whether local anaesthetic wound catheter infiltration (LA-WCI) as an adjunct to intravenous patient-controlled analgesia (IV-PCA) provides superior outcomes compared to IV-PCA alone following liver resection.

METHODS

A systematic review and meta-analysis was conducted for randomised control trials (RCTs) comparing LA-WCI with IV-PCA(LA-WCI group) versus IV-PCA alone (IV-PCA group). PubMed and the Cochrane Library were searched for relevant articles.

RESULTS

Six RCTs with a total of 440 patients were included. Opioid use in the initial 48 h was less in the LA-WCI group [MD -21.27 mg (-39.39,-3.15), p = 0.02]. Pain scores were lower in the LA-WCI group at rest at POD0 (post-operative day 0)6-8 h (p = 0.0009), POD1AM(p = 0.01), POD1PM(p = 0.02) and POD2 (p = 0.0006), and exertion at POD0 0-2 h (p = 0.05), POD1AM(p = 0.03), POD1PM(p = 0.03), POD2 (p = 0.03) and POD3 (p = 0.01). LA-WCI group had reduced length of hospital stay [MD -1.32 days (-2.23,-0.40),p = 0.005], time to ambulation [MD -5.94 h (-8.47,-3.42),p = 0.00001] and incidence of nausea and vomiting (PONV) [OR 0.17 (0.07,0.43),p = 0.0002]. No differences were observed in length of intensive care unit (ICU) stay or incidence of surgical site infections.

DISCUSSION

LA-WCI as an adjunct to opiate IV-PCA post-hepatectomy reduces opioid use, pain scores at multiple time points at rest and exertion, length of hospital stay, time to ambulation and PONV. However, LA-WCI use does not alter length of ICU stay or incidence of wound infection.

Perioperative Management of Complex Hepatectomy for Colorectal Liver Metastases: The Alliance between the Surgeon and the Anesthetist

Hepatic resection has been widely accepted as the first choice for the treatment of colorectal metastases. Liver surgery has been recognized as a major abdominal procedure; it exposes patients to a high risk of perioperative adverse events. Decision sharing and the multimodal approach to the patients' management are the two key items for a safe outcome, even in such a high-risk surgery. This review aims at addressing the main perioperative issues (preoperative evaluation; general anesthesia and intraoperative fluid management and hemodynamic monitoring; intraoperative metabolism; administration policy for blood-derivative products; postoperative pain control; postoperative complications), in particular, from the anesthetist's point of view; however, only an alliance with the surgery team may be successful in case of adverse events to accomplish a good final outcome.

Pain management after open liver resection: Procedure-Specific Postoperative Pain Management (PROSPECT) recommendations

Background and objectives

Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.

Strategy and selection criteria

Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.

Results

Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.

Conclusions

Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.

Anesthesia for the Patient with Severe Liver Failure

The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.

Anesthesia for the Patient with Severe Liver Failure

The incidence of liver failure continues to increase, and it is associated with increased perioperative morbidity and mortality. Liver failure is associated with multiorgan dysfunction, including central nervous, cardiac, respiratory, gastrointestinal, renal, and hematological systems. Preoperative identification, optimization, and tailored anesthetic management are essential for optimum outcomes in patients with liver disease undergoing surgery. The coagulopathy of liver failure is a balanced coagulopathy better assessed by thromboelastography than conventional testing, and it is not directly associated with bleeding risk.

Perioperative Management in Hepatic Resections: Comparative Effectiveness of Neuraxial Anesthesia and Disparity of Care Patterns

BACKGROUND

Complication rates after hepatic resection can be affected by management decisions of the hospital care team and/or disparities in care. This is true in many other surgical populations, but little study has been done regarding patients undergoing hepatectomy.

METHODS

Data from the claims-based national Premier Perspective database were used for 2006 to 2014. The analytical sample consisted of adults undergoing partial hepatectomy and total hepatic lobectomy with anesthesia care consisting of general anesthesia (GA) only or neuraxial and GA (n = 9442). The key independent variable was type of anesthesia that was categorized as GA versus GA + neuraxial. The outcomes examined were clinical complications and health care resource utilization. Unadjusted bivariate and adjusted multivariate analyses were conducted to examine the effects of the different types of anesthesia on clinical complications and health care resource utilization after controlling for patient- and hospital-level characteristics.

RESULTS

Approximately 9% of patients were provided with GA + neuraxial anesthesia during hepatic resection. In multivariate analyses, no association was observed between types of anesthesia and clinical complications and/or health care utilization (eg, admission to intensive care unit). However, patients who received blood transfusions were significantly more likely to have complications and intensive care unit stays. In addition, certain disparities of care, including having surgery in a rural hospital, were associated with poorer outcomes.

CONCLUSIONS

Neuraxial anesthesia utilization was not associated with improvement in clinical outcome or cost among patients undergoing hepatic resections when compared to patients receiving GA alone. Future research may focus on prospective data sources with more clinical information on such patients and examine the effects of GA + neuraxial anesthesia on various complications and health care resource utilization.

Use of perioperative epidural analgesia among Medicare patients undergoing hepatic and pancreatic surgery

BACKGROUND

We sought to characterize epidural analgesia (EA) use among Medicare patients undergoing hepatopancreatic (HP) procedures, identify factors associated with EA use and asses perioperative outcomes.

METHODS

Patients undergoing HP surgery were identified using the Inpatient Standard Analytic Files. Logistic regression was utilized to identify factors associated with EA receipt, and assess associations of EA with in-hospital outcomes and Medicare expenditures.

RESULTS

Among 20,562 patients included in the study, 6.7% (n =1362) had EA. There was no difference in the odds of complications (OR 1.05, 95% CI 0.93-1.19) or blood transfusions (OR 0.90, 95% CI 0.79-1.03) with EA versus conventional analgesia (CA). The odds of prolonged LOS (OR 1.16, 95% CI 1.03-1.30) were higher with EA; the odds of in-hospital mortality were higher with conventional analgesia (OR 1.90, 95% CI 1.28-2.83). Medicare payments for liver surgery were comparable among EA ($19,500) versus conventional analgesia ($19,300, p = 0.85) and slightly higher for EA ($23,600) versus conventional analgesia ($22,000, p < 0.001) for pancreatic procedures.

CONCLUSION

EA utilization among Medicare patients undergoing HP was low. While EA was not associated with morbidity, it resulted in an average additional one day LOS and slightly higher expenditures in pancreatic surgery.

Does epidural analgesia improve the cancer outcome in hepatocellular carcinoma after resection surgery? A retrospective analysis

BACKGROUND

Few studies have investigated the association between epidural analgesia (EA) and oncologic outcomes in patients following hepatocellular carcinoma (HCC) resection.

METHODS

This retrospective study was conducted at a single medical center using electronic medical records. Patients with nonmetastatic primary HCC undergoing tumor resection between January 2005 and December 2011 were classified into two groups based on their use of EA or intravenous analgesia. Multivariate Cox regression analyses were used to evaluate the associations between EA and recurrence-free (RFS) and overall (OS) survival. The patients were also propensity score-matched by demographic and important clinicopathologic variables.

RESULTS

A total of 744 patients (58.5% receiving EA) with a median follow-up time of 64.5 months and 277 matched pairs were included in the analyses before and after matching. No significant association between EA and cancer recurrence or overall mortality was found before matching (RFS: adjusted hazard ratio [HR] = 0.97, 95% CI: 0.80-1.17; OS: adjusted HR = 0.95, 95% CI: 0.71-1.26). After matching, the association between EA and cancer recurrence or overall mortality remained nonsignificant (RFS: HR = 0.89, 95% CI: 0.68-1.17; OS: HR = 1.20, 95% CI: 0.81-1.78).

CONCLUSION

This study did not support a definite association between EA and cancer recurrence or OS in patients with primary HCC after surgical resection.

Enhanced recovery after surgery in liver resection: current concepts and controversies

Enhanced recovery after surgery (ERAS) attenuates the stress response to surgery in the perioperative period and hastens recovery. Liver resection is a complex surgical procedure where the enhanced recovery program has been shown to be safe and effective in terms of postoperative outcomes. ERAS programs have been shown to be associated with lower morbidity, shortened postoperative stay, and reduced cost with no difference in mortality and readmission rates. However, there are challenges that are unique to hepatic resection such as safety after epidural catheterization and postoperative coagulopathy, intraoperative fluids and postoperative organ dysfunction, need for low central venous pressure to reduce blood loss, and non-lactate containing intravenous fluids. This narrative review briefly discusses these concerns and controversies and suggests revisiting some of the strong recommendations made by the ERAS society in light of the recent evidence.

Retrospective analysis of post-operative coagulopathy after major hepatic resection at a tertiary care centre in Northern India

Background and Aims:

Hepatic resection is a major surgery associated with intraoperative massive fluid shifts, blood loss, haemodynamic instability and risk of development of post-hepatectomy liver failure. Hepatic resection predisposes the patient to coagulopathy as well as venous thrombosis. However, due to the development of deranged coagulation profile post-operatively, there is a dilemma in starting thromboprophylaxis. Our aim in this study was to determine the incidence of coagulopathy in patients undergoing major hepatectomy.

Methods:

In this retrospective study, we included 86 patients who had undergone major hepatectomy between January 2010 and December 2015 at our centre. Intraoperatively, we noted the number of liver segments resected, details of epidural catheter insertion, estimated blood loss, transfusion requirement and need for mechanical ventilation post-operatively. Trends of international normalised ratio (INR) and platelet values were recorded until post-operative day 5.

Results:

Of the 86 patients, 6 (7%) had an abnormal coagulation profile pre-operatively and 39 (45.34%) patients developed a derangement in their coagulation profile on 1^st post-operative day (POD). Platelet count was significantly lower and INR values were significantly higher than the pre-operative values on all 5 PODs. Sixty-seven (78%) patients had pre-operative epidural catheter insertion for post-operative pain management. Mechanical thrombophylaxis was used routinely.

Conclusions:

The incidence of post-operative coagulopathy in our patients who underwent major liver resection was 45.34%. Epidural catheters could be removed safely without transfusion between POD 5 and 7. There was no incidence of venous thrombosis or thromboembolism.