Prevalence and risk factors predisposing to coagulopathy in patients receiving epidural analgesia for hepatic surgery. Reg Anesth Pain Med. 2009;34:308-311. [PMID: 19574863 DOI: 10.1097/aap.0b013e3181ac7d00]

The effectiveness and outcomes of epidural analgesia in patients undergoing open liver resection: a propensity score matching analysis

BACKGROUND

Open liver resection necessitates a substantial upper abdominal inverted-L incision, resulting in severe pain and compromising patient recovery. Despite the efficacy of epidural analgesia in providing adequate postoperative analgesia, the potential epidural-related adverse effects should be carefully considered. This study aims to compare the efficacy and safety of continuous epidural analgesia and intravenous analgesia in open liver resection.

METHODS

A retrospective study was conducted, collecting data from patients who underwent open liver resection between 2007 and 2017. Propensity score matching was implemented to mitigate confounding variables, with patients being matched in a 1:1 ratio based on propensity scores. The primary outcome was the comparison of postoperative morphine consumption at 24, 48, and 72 hours between the two groups. Secondary outcomes included pain scores, postoperative outcomes, and epidural-related adverse effects.

RESULTS

A total of 612 patients were included, and after matching, there were 204 patients in each group. Opioid consumption at 24, 48, and 72 hours postoperatively was statistically lower in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001). However, there was no significant difference in pain scores (p = 0.422). Additionally, perioperative hypotension requiring treatment, as well as nausea and vomiting, were significantly higher in the epidural analgesia group compared to the intravenous analgesia group (p < 0.001).

CONCLUSIONS

Epidural analgesia is superior to intravenous morphine in terms of reducing postoperative opioid consumption within the initial 72 h after open liver resection. Nevertheless, perioperative hypotension, which necessitates management, should be approached with consideration and vigilance.

TRIAL REGISTRATION

The study was registered in the Clinical Trials Registry at www.

CLINICALTRIALS

gov/ , NCT number: NCT06301932.

Comparative Evaluation of 0.9% Normal Saline Versus Acetate-Gluconate-Based Balanced Solution on Acid-Base Status and Postoperative Liver Function in Donor Hepatectomy Patients

Background Live donor liver transplantation, a widely practiced procedure, involves resecting a portion of a healthy donor's liver for transplantation. Despite advancements, it poses challenges like cardiovascular instability and electrolyte imbalances, with maintaining acid-base balance being critical. This study compares the effects of 0.9% normal saline and PlasmaLyte A® on acid-base status and postoperative liver function. Methodology This prospective observational study was conducted over one year among 40 healthy adults aged 18-60 years undergoing donor hepatectomy. Patients were alternately allocated to receive either 0.9% saline (Group 1; n = 20) or PlasmaLyte A® (Group 2; n = 20). Key parameters, including acid-base status, hemodynamic parameters, and postoperative liver function, were monitored at various intervals. Statistical analysis was performed using IBM SPSS Statistics for Windows, Version 25.0 (Released 2017; IBM Corp., Armonk, NY, USA), with appropriate statistical tests. A p-value <0.05 was considered statistically significant. Results The study included 40 patients, with 20 in each group. No significant differences were observed between the groups concerning age, gender, weight, hemodynamic parameters, and urine output. However, significant differences were found in acid-base parameters. Group 2 showed better preservation of acid-base balance with higher pH and HCO₃ levels. Patients in Group 1 exhibited a significant decrease in HCO₃ levels during surgery, while those in Group 2 maintained a more stable metabolic profile. Furthermore, nine patients in Group 1 required sodium bicarbonate supplementation for metabolic acidosis, compared to only three in Group 2. Postoperative liver function tests revealed no significant differences between the two groups, although a trend toward better outcomes was observed in Group 2. Conclusions PlasmaLyte A® demonstrated superior preservation of acid-base balance compared to 0.9% normal saline, with less need for bicarbonate supplementation. While liver function outcomes were similar, the balanced solution showed a trend toward better metabolic stability, suggesting it may offer safer and more effective fluid management in liver transplantation surgery.

Development of an enhanced recovery after surgery program for pediatric solid tumors

Introduction

Enhanced recovery after surgery (ERAS) is an evidence-based, multi-modal approach to decrease surgical stress, expedite recovery, and improve postoperative outcomes. ERAS is increasingly being utilized in pediatric surgery. Its applicability to pediatric patients undergoing abdominal tumor resections remains unknown.

Methods and Analysis

A group of key stakeholders adopted ERAS principles and developed a protocol suitable for the variable complexity of pediatric abdominal solid tumor resections. A multi-center, prospective, propensity-matched case control study was then developed to evaluate the feasibility of the protocol. A pilot-phase was utilized prior to enrollment of all patients older than one month of age undergoing any abdominal, retroperitoneal, or pelvic tumor resections. The primary outcome was 90-day complications per patient. Additional secondary outcomes included: ERAS protocol adherence, length of stay, time to administration of adjuvant chemotherapy, readmissions, reoperations, emergency room visits, pain scores, opioid usage, and differences in Quality of Recovery 9 scores.

Ethics and Dissemination

Institutional review board approval was obtained at all participating centers. Informed consent was obtained from each participating patient. The results of this study will be presented at pertinent society meetings and published in peer-reviewed journals. We expect the results will inform peri-operative care for pediatric surgical oncology patients and provide guidance on initiation of ERAS programs. We anticipate this study will take four years to meet accrual targets and complete follow-up.

Trial Registration Number

NCT04344899.

Abnormal coagulation after hepatectomy in patients with normal preoperative coagulation function

BACKGROUND

To explore the risk factors for postoperative abnormal coagulation (PAC) and establish a predictive model for patients with normal preoperative coagulation function who underwent hepatectomy.

MATERIALS AND METHODS

A total of 661 patients with normal preoperative coagulation function who underwent hepatectomy between January 2015 and December 2021 at the First Affiliated Hospital of Sun Yat-sen University were divided into two groups: the postoperative abnormal coagulation group (PAC group, n = 362) and the normal coagulation group (non-PAC group, n = 299). Univariate and multivariate logistic analyses were used to identify the risk factors for PAC.

RESULTS

The incidence of PAC in 661 patients who underwent hepatectomy was 54.8% (362/661). The least absolute shrinkage and selection operator (LASSO) method was used for multivariate logistic regression analysis. The preoperative international normalized ratio (INR), intraoperative succinyl gelatin infusion and major hepatectomy were found to be independent risk factors for PAC. A nomogram for predicting the PAC after hepatectomy was constructed. The model presented a receiver operating characteristic (ROC) curve of 0.742 (95% confidence interval (CI): 0.697-0.786) in the training cohort. The validation set demonstrated a promising ROC of 0.711 (95% CI: 0.639-0.783), and the calibration curve closely approximated the true incidence. Decision curve analysis (DCA) was performed to assess the clinical usefulness of the predictive model. The risk of PAC increased when the preoperative international normalized ratio (INR) was greater than 1.025 and the volume of intraoperative succinyl gelatin infusion was greater than 1500 ml.

CONCLUSION

The PAC is closely related to the preoperative INR, intraoperative succinyl gelatin infusion and major hepatectomy. A three-factor prediction model was successfully established for predicting the PAC after hepatectomy.

Epidural Hematoma in Minor Hepatic Metastasectomy

Liver resection poses many challenges for the anesthesiologist, including intraoperative hemodynamic instability, postoperative pain, and risk of coagulopathy. We report a case of epidural hematoma after epidural catheter removal, following a minor liver single metastasectomy. The main purpose of this case report is to bring to light the false security provided by traditional coagulation parameters and whether further investigation should be considered in selected cases, before handling neuraxial catheters. Alterations in coagulation after a partial hepatectomy remain poorly understood; thus, we believe that additional hemostatic values such as viscoelastic testing might be considered to better assess these patients.

Randomized Prospective Trial of Epidural Analgesia after Open Hepatectomy

OBJECTIVE

To evaluate whether patient-controlled epidural analgesia (PCEA) improves postoperative pain during ambulation following elective open hepatectomy.

BACKGROUND

Strategies to alleviate postoperative pain are a critical element of recovery after surgery. However, the optimal postoperative pain management strategy following open hepatectomy remains unclear.

METHODS

We conducted a prospective, nonblinded, randomized comparison of PCEA (intervention) versus intravenous patient-controlled analgesia (IV PCA; control) for postoperative pain following elective open hepatectomy. The primary end point was pain during ambulation on postoperative day (POD) 2. The study was powered to detect a clinically significant 2-point difference on the pain numeric rating scale (NRS). Secondary end points included pain at rest, morbidity, time to return of bowel function, and length of stay.

RESULTS

From 2015 to 2020, 231 patients were randomized (116 patients in the PCEA arm and 115 in the IV PCA arm). The incidence of epidural failure was 3% (n=4/116), with no epidural-related complications. Patients in the PCEA arm had a <2-point difference in NRS pain scores during ambulation on POD 2 vs. IV PCA (median 4.0 vs. 5.0, P <0.001). There was no difference in overall complications between the PCEA and IV PCA arms (33% vs. 40%, P =0.276). Secondary outcomes, including pain scores at rest, were similar between the study arms.

CONCLUSIONS

PCEA was safe following open hepatectomy and was associated with a small difference in pain with activity on POD 2 that did not reach our pre-specified definition of clinical significance.

Analgesic efficacy of an opioid-free postoperative pain management strategy versus a conventional opioid-based strategy following open major hepatectomy: an open-label, randomised, controlled, non-inferiority trial

Background

Convincing clinical evidence regarding completely opioid-free postoperative pain management using erector spinae plane block (ESPB) in patients undergoing open major hepatectomy (OMH) is lacking. Herein, we aimed to compare the postoperative analgesic efficacy of the visualised continuous opioid-free ESPB (VC-ESPB) and conventional intravenous opioid-based postoperative pain management in hepatocellular carcinoma (HCC) patients undergoing OMH.

Methods

This open-label, randomised, controlled, non-inferiority trial enrolled patients with HCC undergone open major hepatectomy in Fujian Provincial Hospital and compared the postoperative analgesic efficacy of VC-ESPB (VC-ESPB group) and conventional intravenous opioid-based pain management regimen (conventional group). Patients were randomly assigned (1:1) to VC-ESPB group and conventional group. Patients were not masked to treatment allocation. The VC-ESPB group was treated with intermittent injections of 0.25% ropivacaine (bilateral, 30 mL each side) given every 12 h through catheters placed in the space of erector spinae and an opioid-free intravenous pump (10-mg tropisetron diluted to 100 mL with 0.9% normal saline [NS]) for postoperative pain management. The conventional group did not receive ESPB and was treated with a conventional intravenous opioid-based pump (2.5-μg/kg sufentanil and 10-mg tropisetron diluted to 100 mL with 0.9% NS). Patients in the VC-ESPB group underwent magnetic resonance imaging (MRI) to identify local anaesthetic diffusion after ESPB was performed under ultrasound guidance. The primary outcome was postoperative analgesic efficacy, which was indicated by the cumulative area under the curve (AUC) of the pain visual analogue scale scores (range, 0-10; a higher score indicates more pain) obtained at rest and at movement until 48 h postoperatively after leaving the post-anaesthesia care unit (PACU). Herein, an AUC of 26.5 was set as the noninferiority margin, which needed to be satisfied for both cumulative AUCPACU-48 h at rest and cumulative AUCPACU-48 h at movement. Per protocol participants were included in primary and safety analyses. This trial was registered with ChiCTR.org.cn (ChiCTR1900026583).

Findings

Between October 30, 2019, and May 1, 2023, 106 patients were enrolled and randomly assigned to the VC-ESPB group (n = 53) and the conventional group (n = 53). After the dropout (n = 5), a total of 101 patients (VC-ESPB group, n = 50; conventional group, n = 51) were analysed. Both the level of cumulative AUCPACU-48 h (at rest: 160.08 ± 38.00 vs. 164.94 ± 31.00; difference [90% CI], -4.861 [-16.308, 6.585]) and cumulative AUCPACU-48 h (at movement: 209.64 ± 28.98 vs. 212.59 ± 33.11; difference [90% CI], -2.948 [-13.236, 7.339]) were similar between the VC-ESPB and control groups within the first postoperative 48 h. The upper limit of the 90% CIs for the difference in cumulative ACUPACU-48 h at rest and at movement did not reach the upper inferiority margin (26.5). During the first postoperative 48 h, the rate of nonsteroidal anti-inflammatory drug rescue analgesia was similar between the VC-ESPB group and conventional group (n = 16, 32.0% vs. n = 11, 21.6%; P = 0.236). Treatment-related death was not observed in the VC-ESPB group (n = 0, 0%) and conventional group (n = 0, 0%). In VC-ESPB group, local site paralysis (n = 1, 2.0%) was observed in one patient and rash (n = 1, 2.0%) was observed in another patient. One patient in the conventional group was observed with rash preoperatively (n = 1, 2.0%). The VC-ESPB group had significantly lower rates of postoperative nausea (n = 2, 4.0%, vs. n = 9, 17.6%, P = 0.028), vomiting (n = 1, 2.0% vs. n = 8, 15.7%, P = 0.031) and lower incidence of major complications (n = 4, 8.0% vs. n = 6, 11.8%; P = 0.033).

Interpretation

This study demonstrates the noninferiority of VC-ESPB when compared with the conventional opioid-based approach for postoperative pain management after OMH, suggesting that it is feasible to achieve opioid-free postoperative pain management for OMH.

Funding

The Joint Funds for the Innovation of Science and Technology, Fujian Province, China; the Youth Scientific Research Project of Fujian Provincial Health Commission; the Fujian Research and Training Grants for Young and Middle-aged Leaders in Healthcare; and the Key Clinical Specialty Discipline Construction Program of Fujian, China.

Intrathecal hydromorphone for analgesia after partial hepatectomy: a randomized controlled trial

INTRODUCTION

There is substantial interest in adding intrathecal opioids, such as hydromorphone to the multimodal pain management strategies. We conducted a randomized controlled trial to examine whether adding intrathecal hydromorphone to a multimodal strategy could safely improve analgesic efficacy for patients undergoing partial hepatectomy.

METHODS

A total of 126 adult patients undergoing partial hepatectomy under general anesthesia were randomly assigned to receive intrathecal hydromorphone (100 μg) or no block. The primary outcome was the incidence of moderate to severe pain during movement at 24 hours after surgery. Secondary outcomes included the incidence of moderate to severe pain during rest or movement at different times within 72 hours, pain scores during rest or movement within 72 hours after surgery, analgesic use, adverse events, and indicators of postoperative recovery.

RESULTS

Among the 124 patients analyzed, the intrathecal hydromorphone group showed a lower incidence of moderate to severe pain during movement at 24 hours after surgery (29.0% vs 50%; RR 0.58, 95% CI 0.37 to 0.92) than the control group. However, the absolute difference in pain scores on a numerical rating scale was less than 1 between the two groups at 24 hours after surgery. Mild pruritus within the first 24 hours after surgery was more frequent in the intrathecal hydromorphone group (19.4% vs 4.8%; p=0.01).

DISCUSSION

Intrathecal hydromorphone 100 μg reduced the incidence of moderate to severe pain and pain scores during movement within 24 hours after partial hepatectomy. However, the difference in pain scores may not be clinically significant, and intrathecal hydromorphone 100 μg did not significantly improve other analgesic or functional outcomes. Further investigation is needed to optimize the intrathecal hydromorphone dose.

TRIAL REGISTRATION NUMBER

ChiCTR2000030652.

Postoperative Analgesia after Open Liver Surgery: Systematic Review of Clinical Evidence

Background: The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery. Methods: The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors’ agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design. Results: The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review. Conclusions: The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a “blended approach” which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative “stress hormones”, and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.

Metalloproteinase expression after desflurane preconditioning in hepatectomies: A randomized clinical trial

BACKGROUND

Hepatectomy with inflow occlusion results in ischemia-reperfusion injury; however, pharmacological preconditioning can prevent such injury and optimize the postoperative recovery of hepatectomized patients. The normal inflammatory response after a hepatectomy involves increased expression of metalloproteinases, which may signal pathologic hepatic tissue reformation.

AIM

To investigate the effect of desflurane preconditioning on these inflammatory indices in patients with inflow occlusion undergoing hepatectomy.

METHODS

This is a single-center, prospective, randomized controlled trial conducted at the 4^th Department of Surgery of the Medical School of Aristotle University of Thessaloniki, between August 2016 and December 2017. Forty-six patients were randomized to either the desflurane treatment group for pharmacological preconditioning (by replacement of propofol with desflurane, administered 30 min before induction of ischemia) or the control group for standard intravenous propofol. The primary endpoint of expression levels of matrix metalloproteinases and their inhibitors was determined preoperatively and at 30 min posthepatic reperfusion. The secondary endpoints of neutrophil infiltration, coagulation profile, activity of antithrombin III (AT III), protein C (PC), protein S and biochemical markers of liver function were determined for 5 d postoperatively and compared between the groups.

RESULTS

The desflurane treatment group showed significantly increased levels of tissue inhibitor of metalloproteinases 1 and 2, significantly decreased levels of matrix metalloproteinases 2 and 9, decreased neutrophil infiltration, and less profound changes in the coagulation profile.  During the 5-d postoperative period, all patients showed significantly decreased activity of AT III, PC and protein S (vs baseline values, P < 0.05). The activity of AT III and PC differed significantly between the two groups from postoperative day 1 to postoperative day 5 (P < 0.05), showing a moderate drop in activity of AT III and PC in the desflurane treatment group and a dramatic drop in the control group. Compared to the control group, the desflurane treatment group also had significantly lower international normalized ratio values on all postoperative days (P < 0.005) and lower serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase values on postoperative days 2 and 3 (P < 0.05).   Total length of stay was significantly less in the desflurane group (P = 0.009).

CONCLUSION

Desflurane preconditioning can lessen the inflammatory response related to ischemia-reperfusion injury and may shorten length of hospitalization.

Epidural Anesthesia in Liver Surgery-A Propensity Score-Matched Analysis

OBJECTIVE

To assess the effects of epidural anesthesia (EA) on patients who underwent liver resection.

DESIGN

Secondary analysis of a prospective randomized controlled trial.

SETTING

This single-center study was conducted at an academic medical center.

METHODS

A subset of 110 1:1 propensity score-matched patients who underwent liver resection with and without EA were analyzed. Outcome measures were pain intensity ≥5 on a numeric rating scale (NRS) at rest and during movement on postoperative days 1-5, analyzed with logistic mixed-effects models, and postoperative complications according to the Clavien-Dindo classification, length of hospital stay (LOS), and one-year survival. One-year survival in the matched cohorts was compared using a frailty model.

RESULTS

EA patients were less likely to experience NRS ≥5 at rest (odds ratio = 0.06, 95% confidence interval [CI] = 0.01 to 0.28, P < 0.001). These findings were independent of age, sex, Charlson comorbidity index, baseline NRS, and surgical approach (open vs laparoscopic). The number and severity of postoperative complications and LOS were comparable between groups (P = 0.258, P > 0.999, and P = 0.467, respectively). Reduced mortality rates were seen in the EA group one year after surgery (9.1% vs 30.9%, hazard ratio = 0.32, 95% CI = 0.11 to 0.90, P = 0.031). No EA-related adverse events occurred. Earlier recovery of bowel function was seen in EA patients.

CONCLUSIONS

Patients with EA had better postoperative pain control and required fewer systemic opioids. Postoperative complications and LOS did not differ, although one-year survival was significantly improved in patients with EA. EA applied in liver surgery was effective and safe.

Medial Open Transversus Abdominis Plane (MOTAP) Catheters Reduce Opioid Requirements and Improve Pain Control Following Open Liver Resection: A Multicenter, Blinded, Randomized Controlled Trial

OBJECTIVE

Conventional management of pain following open liver resection involves intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. The objective of this trial was to assess the efficacy of a regional technique called Medial Open Transversus Abdominis Plane (MOTAP) catheter analgesia compared with IV PCA.

METHODS

This was a blinded, randomized, controlled parallel-arm trial conducted at 2 high-volume centers. Patients undergoing liver resection through a subcostal incision were enrolled. Using a standardized technique, 2 catheters were placed after resection: one in the plane between internal oblique and transversus abdominis and the other in the posterior rectus sheath. Patients were randomized to receive ropivacaine 0.2% (ROP) or saline (NS) through both catheters for 72 hours. All patients received IV PCA with hydromorphone as part of a multimodality analgesia program. Primary outcome was opioid use over the first 48 hours.

RESULTS

One hundred fifty-three patients were included in the analysis (71 ROP, 82 NS). Patients receiving ROP used significantly less opioid than patients with NS at 48 hours (median 39.6 mg morphine-equivalent vs 49.2 mg, P = 0.033) and at 72 hours (median 50.0 vs 66.4 mg, P = 0.046). Pain scores at rest and with coughing were significantly lower at all time points in patients who received ROP (P = 0.002). Median length of hospital stay was 5 days in patients receiving ROP and 6 days in patients who received NS (P = 0.035). There was no difference between groups in complications [ROP 20 (28.2%) vs NS 26 (31.7%), P = 0.63].

CONCLUSION

MOTAP catheter analgesia reduces opioid requirements, pain, and length of hospital stay compared with IV PCA following open liver resection with subcostal incisions.

Analysis of the postoperative hemostatic profile of colorectal cancer patients subjected to liver metastasis resection surgery

BACKGROUND

Liver resection surgery has advanced greatly in recent years, and the adoption of fasttrack programs has yielded good results. Combination anesthesia (general anesthesia associated to epidural analgesia) is an anesthetic-analgesic strategy commonly used for the perioperative management of patients undergoing surgery of this kind, though there is controversy regarding the coagulation alterations it may cause and which can favor the development of spinal hematomas.

AIM

To study the postoperative course of liver resection surgery, an analysis was made of the outcomes of liver resection surgery due to colorectal cancer metastases in our centre in terms of morbiditymortality and hospital stay according to the anesthetic technique used (general vs combination anesthesia).

METHODS

A prospective study was made of 61 colorectal cancer patients undergoing surgery due to liver metastases under general and combination anesthesia between January 2014 and October 2015. The patient characteristics, intraoperative variables, postoperative complications, evolution of hemostatic parameters, and stay in intensive care and in hospital were analyzed.

RESULTS

A total of 61 patients were included in two homogeneous groups: general anesthesia (n = 30) and combination anesthesia (general anesthesia associated to epidural analgesia) (n = 31). All patients had normal coagulation values before surgery. The international normalized ratio (INR) in both the general and combination anesthesia groups reached maximum values at 2448 h (mean 1.37 and 1.45 vs 1.39 and 1.41, respectively), followed by a gradual decrease. There was less intraoperative bleeding in the combination anesthesia group (769 mL) than in the general anesthesia group (1200 mL) (P < 0.05). Of the 61 patients, 38.8% in the general anesthesia group experienced some respiratory complication vs 6.6% in the combination anesthesia group (P < 0.001). The time to gastrointestinal tolerance was significantly correlated to the type of anesthesia, though not so the stay in critical care or the time to hospital discharge.

CONCLUSION

Epidural analgesia in liver resection surgery was seen to be safe, with good results in terms of pain control and respiratory complications, and with no associated increase in complications secondary to altered hemostasis.

Incidence and Risk Factors of Coagulation Profile Derangement After Liver Surgery: Implications for the Use of Epidural Analgesia-A Retrospective Cohort Study

BACKGROUND

Hepatic surgery is a major abdominal surgery. Epidural analgesia may decrease the incidence of postoperative morbidities. Hemostatic disorders frequently occur after hepatic resection. Insertion or withdrawal (whether accidental or not) of an epidural catheter during coagulopathic state may cause an epidural hematoma. The aim of the study is to determine the incidence of coagulopathy after hepatectomy, interfering with epidural catheter removal, and to identify the risk factors related to coagulopathy.

METHODS

We performed a retrospective review of a prospective, multicenter, observational database including patients over 18 years old with a history of liver resection. Main collected data were the following: age, preexisting cirrhosis, Child-Pugh class, preoperative and postoperative coagulation profiles, extent of liver resection, blood loss, blood products transfused during surgery. International normalized ratio (INR) ≥1.5 and/or platelet count <80,000/mm defined coagulopathy according to the neuraxial anesthesia guidelines. A logistic regression analysis was performed to assess the association between selected factors and a coagulopathic state after hepatic resection.

RESULTS

One thousand three hundred seventy-one patients were assessed. Seven hundred fifty-nine patients had data available about postoperative coagulopathy, which was observed in 53.5% [95% confidence interval, 50.0-57.1]. Maximum derangement in INR occurred on the first postoperative day, and platelet count reached a trough peak on postoperative days 2 and 3. In the multivariable analysis, preexisting hepatic cirrhosis (odds ratio [OR] = 2.49 [1.38-4.51]; P = .003), preoperative INR ≥1.3 (OR = 2.39 [1.10-5.17]; P = .027), preoperative platelet count <150 G/L (OR = 3.03 [1.77-5.20]; P = .004), major hepatectomy (OR = 2.96 [2.07-4.23]; P < .001), and estimated intraoperative blood loss ≥1000 mL (OR = 1.85 [1.08-3.18]; P = .025) were associated with postoperative coagulopathy.

CONCLUSIONS

Coagulopathy is frequent (53.5% [95% confidence interval, 50.0-57.1]) after liver resection. Epidural analgesia seems safe in patients undergoing minor hepatic resection without preexisting hepatic cirrhosis, showing a normal preoperative INR and platelet count.

Clinical effect of enoxaparin on international normalized ratio following hepato-pancreatico-biliary and gastroesophageal resection

BACKGROUND AND OBJECTIVES

Enoxaparin inactivates factor Xa via a complex formed after binding to circulating anti-thrombin III. This mechanism is reported not to alter hemostatic measures such as clotting time, PT, or PTT. To date, no clinical trials have shown a causal relationship between the clinical/pharmacological effects of enoxaparin on international normalized ratio (INR). The aim of our study is to show the clinical effect of enoxaparin on INR.

METHODS

Patients (N = 350) were reviewed from our prospective IRB approved databases undergoing gastroesophageal or hepatobiliary surgeries. INR levels were recorded for 6 days: pre-operative to 5 days after surgery.

RESULTS

Patients (N = 289) received enoxaparin daily starting post-operative day 1, while 61 patients who did not receive enoxaparin were used as controls. The mean post-operative INR in both the 30 and 40 mg groups were both significantly higher than the mean post-operative INR of the control group (P = 0.015 and P = 0.00075, respectively); however postoperative hemoglobin levels were not significantly lower in the enoxaparin versus control.

CONCLUSION

This is the first clinical evidence of the effect of enoxaparin on INR in patients undergoing abdominal surgeries for malignancies. We demonstrate an increase in the INR for patients who received enoxaparin for post-operative VTE prophylaxis.

The Opioid-Sparing Effect of Perioperative Dexmedetomidine Combined with Oxycodone Infusion during Open Hepatectomy: A Randomized Controlled Trial

Background: A large right subcostal incision performed by open hepatectomy is associated with significant post-operative pain and distress. However, post-operative analgesia solutions still need to be devised. We investigated the effects of intra- and post-operative infusion of dexmedetomidine (Dex) combined with oxycodone during open hepatectomy.

Methods: In this prospective, randomized and double-blind investigation, 52 patients undergoing selective open hepatectomy were divided into Dex group (DEX infusion at an initial loading dose of 0.5 μg⋅kg^-1 over 10 min before intubation then adjusted to a maintenance dose of 0.3 μg⋅kg^-1⋅h^-1 until incision suturing) or control (Con) group (0.9% sodium chloride was administered). Patient-controlled analgesia was administered for 48 h after surgery (Dex group: 60 mg oxycodone and 360 μg DEX diluted to 120 ml and administered at a bolus dose of 2 ml, with 5 min lockout interval and a 1 h limit of 20 ml. Con group: 60 mg oxycodone alone with the same regimen). The primary outcome was post-operative oxycodone consumption. The secondary outcomes included requirement of narcotic and vasoactive drugs, hemodynamics, incidence of adverse effects, satisfaction, first exhaust time, pain intensity, and the Ramsay Sedation Scale.

Results: Post-operative oxycodone consumption was significantly reduced in Dex group from 4 to 48 h after surgery (P < 0.05). Heart rate in Dex group was statistically decreased from T1 (just before intubation) to T6 (20 min after arriving at the post-anesthesia care unit), while mean arterial pressure was significantly decreased from T1 to T3 (during surgical incision; P < 0.05). The consumption of propofol and remifentanil were significantly decreased in Dex group (P < 0.05). The VAS scores at rest at 1, 4, and 8 h and with cough at 24, and 48 h after surgery were lower, the first exhaust time were shorter, satisfaction with pain control was statistically higher and the incidence of nausea and vomiting was less in Dex group than in Con group (all P < 0.05).

Conclusion: The combination of DEX and oxycodone could reduce oxycodone consumption and the incidence of nausea and vomiting, enhance the analgesic effect, improves patient satisfaction and shorten the first exhaust time.

Pre- to postoperative coagulation profile of 307 patients undergoing oesophageal resection with epidural blockade over a 10-year period in a single hospital: implications for the risk of spinal haematoma

Background

Epidural anaesthesia and analgesia are indicated for oesophageal surgery. A rare but serious complication is spinal haematoma, which can occur on insertion, manipulation or withdrawal of catheters. Evidence and guidelines are vague regarding which tests are appropriate and how to interpret their results. We aimed to describe how routine coagulation test results change during oesophagectomy’s perioperative course.

Methods

Following ethical approval, we retrospectively identified patients who had undergone oesophagectomy between 2002 and 2012. Blood test results and details of operations, haemorrhage and complications were recorded and analysed with Excel and R. A literature search was conducted using the PubMed terms ‘epidural’ AND ‘coagulation’ AND English language. Relevant articles published in 2000 and after were included.

Results

Three hundred and seven patients received a thoracic epidural infusion with bupivacaine and morphine while 51 received an intravenous morphine infusion. Tests taken preoperatively and before the planned withdrawal of the epidural catheter demonstrated increases in all three measures: aPTT (activated partial thromboplastin time), PT-INR (prothrombin international normalised ratio) and platelet count (Plc). Postoperative thrombocytopenia was almost non-existent while aPTT or PT-INR was elevated above the reference range in 129/307 patients: aPTT was elevated in 116/307 while PT-INR was elevated in 32/307. This is too small a sample to allow meaningful estimation of risk of spinal haematoma: it may be as high as 2.3%. The literature search returned 275 articles, of which 57 were relevant. Twenty-one concerned the natural history of postoperative coagulation; 16, the incidence of and risk factors for spinal haematoma; and 5, evaluation of specific blood tests. Postoperative coagulation is characterised by thrombocytosis and transient moderately abnormal routine coagulation test results. Viscoelastic tests are not validated in the stable postoperative setting.

Conclusions

Screening for coagulopathy before removal of epidural catheters is of unclear benefit since elevated aPTT and PT-INR are usual and may not indicate hypocoagulation. A thorough clinical assessment is important. We nevertheless recommend caution when being presented with elevated routine tests of coagulation before withdrawing an epidural catheter: viscoelastic haemostatic tests may have a role in testing before withdrawal of epidural catheters but they are so far not validated. Future research should include advanced coagulation analysis as soon as a patient is unfortunate enough to have a spinal haematoma.

Electronic supplementary material

The online version of this article (10.1186/s13741-017-0070-7) contains supplementary material, which is available to authorized users.

A new technique for accelerated liver regeneration: An experimental study in rats

BACKGROUND

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is used to accelerate growth of the future liver remnant. We investigated alternative methods for increasing the future liver remnant.

METHODS

A total of 152 rats were randomized as follows: (1) sham; (2) portal vein ligation; (3) portal vein ligation/surgical split (ALPPS); (4) portal vein ligation/split of the liver with a radiofrequency ablation needle; (5) portal vein ligation/radiofrequency ablation of the deportalized liver (portal vein ligation/radiofrequency ablation necrosis in the deportalized liver); (6) portal vein ligation/radiofrequency ablation of the future liver remnant (portal vein ligation/radiofrequency ablation-future liver remnant); and (7) controls. Animals were evaluated on postoperative days 2 and 4. Bodyweight, liver parameters, hepatic regeneration rate, proinflammatory cytokines, hepatocyte proliferation, and gene expression were measured.

RESULTS

Hepatic regeneration rate indicated a steady increase in all intervention groups compared with sham rats (P < .001). At postoperative day 2, the hepatic regeneration rate was significantly higher in the portal vein ligation/radiofrequency ablation necrosis in the deportalized liver group than in the portal vein ligation group (P = .039). On postoperative day 4, we found significant differences between the portal vein ligation group and the ALPPS (P = .015), portal vein ligation/split of the liver with a radiofrequency ablation needle (P = .010), and portal vein ligation/radiofrequency ablation necrosis in the deportalized liver (P = .046) groups. Hepatocyte proliferation was significantly higher at all times compared with sham rats. On postoperative day 4, we found a significantly higher proliferation in groups 3, 4, 5, and 6 compared to portal vein ligation. Gene analysis revealed upregulation of genes involved in cellular proliferation and downregulation of genes involved in cellular homeostasis in all intervention groups. Between the intervention groups, gene expression was nearly identical. Biochemical markers and proinflammatory cytokines were comparable between groups.

CONCLUSION

The surplus liver regeneration after ALPPS is probably mediated through parenchymal damage and subsequent release of growth stimulators, which again upregulates genes involved in cellular regeneration and downregulates genes involved in cellular homeostasis. We also demonstrate that growth of the future liver remnant, comparable to that seen after ALPPS, could be achieved by radiofrequency ablation treatment of the deportalized liver, that is, a procedure in which the initial step in humans can be performed percutaneously.

Epidural Versus Paravertebral Nerve Block for Postoperative Analgesia in Patients Undergoing Open Liver Resection: A Randomized Clinical Trial

BACKGROUND AND OBJECTIVES

Although many studies have found no difference between thoracic epidural block and unilateral thoracic paravertebral block after thoracotomy, no previous studies have compared epidural block with bilateral thoracic paravertebral block (bTPVB) in patients undergoing open liver resection. We aimed to investigate whether there was a significant analgesic advantage of thoracic epidural over bTPVB after liver resection.

METHODS

This randomized, prospective, open-label study included adult patients undergoing elective open liver resection. Patients were randomized to receive either thoracic epidural block or bTPVB, through which ropivacaine (0.2%) was infused for 3 days. The primary outcome was pain Verbal Rating Scale (VRS) score (0-10) at rest and with postoperative incentive spirometry. Secondary outcomes included VRS at rest, inspired volumes during incentive spirometry, patient-controlled analgesia hydromorphone utilization, measures of hemodynamic stability, and postoperative bowel function.

RESULTS

Eighty patients completed the study and received thoracic epidural block (n = 41) or bTPVBs (n = 39). No catheter-related complications were noted. The primary outcome, pain (VRS) with incentive spirometry, was significantly lower in the epidural group (epidural vs bTPVB, mean [SD]) (4.5 [2.7] vs 5.4 [2.7] at 24 hours postoperatively, and 3.2 [2.1] vs 4.6 [2.4] at 48 hours postoperatively). Maximal inspired volumes at 24 hours postoperatively (917 [379] vs 1042 [468] mL) and cumulative utilization of patient-controlled analgesia hydromorphone during the first 48 hours postoperatively (10.7 [7.9] vs 13.6 [8.5] mg) were not significantly different between groups. Decrease in mean arterial pressure from baseline at 24 hours postoperatively was greater for the epidural group (-12.6 [15.8] vs -3.8 [16.2]; P = 0.016).

CONCLUSIONS

This study suggests that there is a modest analgesic advantage of thoracic epidural over bTPVBs for patients after open liver resection.

Epidural anesthesia and analgesia in liver resection: Safety and effectiveness

OBJECTIVES

Perioperative epidural analgesia in liver resection provides optimal dynamic pain relief. Coagulation disorders occurring in the postoperative period can lead to greater risk of complications during epidural catheter removal. The aim of this study is to evaluate the effectiveness and complications of epidural analgesia and delayed epidural catheter removal due to postoperative coagulopathy.

METHODS

A retrospective study of 114 patients undergoing open liver resection and epidural analgesia, from March 2012 to February 2015. Postoperative course of pain intensity, coagulation parameters and delayed catheter removal was analyzed RESULTS: Of the 114 operated patients, 73 met the inclusion criteria. 59% of patients received major hepatectomy (resection ≥ 3 segments) and 15% had Child's Class A cirrhosis (11/73). 96% of catheters functioned properly. 89% of patients had controlled pain (numerical rate scale <3) at rest and 8.2% (6 patients) had severe pain (numerical rate scale > 6) with movement. The INR peaked on postoperative day 2, 1.41 [0.99-2.30], and gradually returned to normal values in most patients by postoperative day 4, 1.26 [0.90 - 2.20]. The catheters were left in place 3.6 (± 1.1) days. In 6 patients (8%), catheter removal was postponed due to coagulation disorders.

CONCLUSIONS

Epidural analgesia for liver resection was a safe practice, which produced optimal control of postoperative pain. The percentage of delayed catheter removal due to postoperative coagulopathy was low, not requiring transfusion of blood products.

Grading of peripheral cytopenias caused by nonalcoholic cirrhotic portal hypertension and its clinical significance

This study investigates peripheral cytopenias in patients with splenomegaly caused by nonalcoholic cirrhotic portal hypertension. Data from 330 splenomegaly cases caused by nonalcoholic cirrhotic portal hypertension were collected and analyzed using univariate and multivariate analysis. The cytopenias were scored and graded according to the F value of the multiple linear regression equation. Based on the severity of thrombocytopenia, cytopenia was graded as mild, moderate, or severe, and determined by a score of <2 points, 2-3 points, and >3 points. 30 % of the patients had monolineage cytopenias, 35.8 % had bilineage cytopenias, and 34.2 % had trilineage cytopenias. All patients were treated surgically. In the univariate analysis, the severity of erythropenia was different in the surgical outcome when compared to the intra-group (P < 0.05). In the multivariate analysis, thrombocytopenia was different in the surgical outcomes when compared with leukopenia and erythropenia (P < 0.05). There was a significant difference in surgical outcomes between the three grades (mild, moderate, and severe) of cytopenia (P < 0.05). Peripheral cytopenias have a significant impact on the clinical outcomes. The more severe the cytopenias, the worse the surgical outcomes are. Thrombocytopenia is a major factor influencing surgical outcomes. The thrombocytopenia-based three-level grading of cytopenias provides a basis for analyzing individual cases, planning treatment, and assessing prognosis in clinical practice.

Risk factors for coagulopathy after liver resection

STUDY OBJECTIVE

To identify risk factors for coagulopathy in patients undergoing liver resection.

DESIGN

A retrospective cohort study.

SETTING

Patients who underwent liver resection at a university hospital between April 2010 and May 2011 were evaluated within seven days after surgery.

PATIENTS

One hundred forty-seven patients were assessed for eligibility. Thirty needed to be excluded because of incomplete data (23) or a preexisting coagulopathy (7).

MEASUREMENTS

Coagulopathy was defined as 1 or more of the following events: international normalized ratio ≥1.4, platelet count <80,000/μL, and partial thromboplastin time >38 seconds. Related to the time course and coagulation profile thresholds, 3 different groups could be distinguished: no coagulopathy, temporary coagulopathy, and persistent coagulopathy.

MAIN RESULTS

Seventy-seven patients (65.8%) had no coagulopathy, whereas 33 (28.2%) developed temporary coagulopathy and 7 (6%) developed persistent coagulopathy until day 7. Preoperative international normalized ratio (P = .001), postoperative peak lactate levels (P = .012), and resected liver weight (P = .005) were identified as independent predictors. Preoperative liver transaminases and transfusion volumes of red blood cells and fresh frozen plasma were significantly higher in patients with persistent coagulopathy.

CONCLUSIONS

Epidural anesthesia is feasible in patients scheduled for liver resection. Caution should be observed for patients with extended resection (≥3 segments) and increased postoperative lactate. In patients with preexisting liver disease, epidural catheters should be avoided.

Factors associated with failure of enhanced recovery protocol in patients undergoing major hepatobiliary and pancreatic surgery: a retrospective cohort study

OBJECTIVE

This study examined the risk factors associated with failure of enhanced recovery protocol after major hepatobiliary and pancreatic (HBP) surgery.

SETTING AND PARTICIPANTS

A retrospective cohort of 194 adult patients undergoing major HBP surgery at a university hospital in Hong Kong was followed up for 30 days. The patients were from a larger cohort study of 736 consecutive adults with preoperative urinary cotinine concentration to examine the association between passive smoking and risk of perioperative respiratory complications and postoperative morbidities.

OUTCOME MEASURES

The primary outcome was failure of enhanced recovery protocol. This was defined as a composite measure of the following events: intensive care unit (ICU) stay more than 24 h after surgery, unplanned admission to ICU within 30 days after surgery, hospital readmission, reoperation and mortality.

RESULTS

There were 25 failures of enhanced recovery after HBP surgery (12.9%, 95% CI 8.5% to 18.4%). After adjusting for elective ICU admission, smokers (relative risk (RR ) 2.21, 95% CI 1.10 to 4.46), high preoperative alanine transaminase/glutamic-pyruvic transaminase (RR 3.55,95% CI 1.68 to 7.49) and postoperative morbidities (RR 2.69, 95% CI 1.30 to 5.56) were associated with failures of enhanced recovery in the generalised estimating equation risk model. Compared with those managed successfully, failures stayed longer in ICU (median 19 vs 25 h, p<0.001) and in hospital for postoperative care (median 7 vs 13 days, p=0.003).

CONCLUSIONS

Smokers and patients having high preoperative alanine transaminase/glutamic-pyruvic transaminase concentration or have a high risk of postoperative morbidities are likely to fail enhanced recovery protocol in HBP surgery programmes.

Medial open transversus abdominis plane (MOTAP) catheters for analgesia following open liver resection: study protocol for a randomized controlled trial

BACKGROUND

The current standard for pain control following liver surgery is intravenous, patient-controlled analgesia (IV PCA) or epidural analgesia. We have developed a modification of a regional technique called medial open transversus abdominis plane (MOTAP) catheter analgesia. The MOTAP technique involves surgically placed catheters through the open surgical site into a plane between the internal oblique muscle and the transverse abdominis muscle superiorly. The objective of this trial is to assess the efficacy of this technique.

METHODS/DESIGN

This protocol describes a multicentre, prospective, blinded, randomized controlled trial. One hundred and twenty patients scheduled for open liver resection through a subcostal incision will be enrolled. All patients will have two MOTAP catheters placed at the conclusion of surgery. Patients will be randomized to one of two parallel groups: experimental (local anaesthetic through MOTAP catheters) or placebo (normal saline through MOTAP catheters). Both groups will also receive IV PCA. The primary endpoint is mean cumulative postoperative opioid consumption over the first 2 postoperative days (48 hours). Secondary outcomes include pain intensity, patient functional outcomes, and the incidence of complications.

DISCUSSION

This trial has been approved by the ethics boards at participating centres and is currently enrolling patients. Data collection will be completed by the end of 2014 with analysis mid-2015 and publication by the end of 2015.

TRIAL REGISTRATION

The study is registered with http://clinicaltrials.gov ( NCT01960049; 23 September 2013).

Systematic review of pathophysiological changes following hepatic resection

OBJECTIVES

Major hepatic resection is now performed frequently and with relative safety, but is accompanied by significant pathophysiological changes. The aim of this review is to describe these changes along with interventions that may help reduce the risk for adverse outcomes after major hepatic resection.

METHODS

The MEDLINE, EMBASE and CENTRAL databases were searched for relevant literature published from January 2000 to December 2011. Broad subject headings were 'hepatectomy/', 'liver function/', 'liver failure/' and 'physiology/'.

RESULTS

Predictable changes in blood biochemistry and coagulation occur following major hepatic resection and alterations from the expected path indicate a complicated course. Susceptibility to sepsis, functional renal impairment, and altered energy metabolism are important sequelae of post-resection liver failure.

CONCLUSIONS

The pathophysiology of post-resection liver failure is difficult to reverse and thus strategies aimed at prevention are key to reducing morbidity and mortality after liver surgery.

Peripheral blood cell variations in cirrhotic portal hypertension patients with hypersplenism

OBJECTIVE

To explore peripheral blood cell variations in hepatic cirrhosis portal hypertension patients with hypersplenism.

METHODS

Clinical data of 322 hypersplenism patients with decreased peripheral blood cells, admitted with cirrhotic portal hypertension, was retrospectively studied over the last 17 years.

RESULTS

In 64% (206/322) of patients, more than 2 kinds of blood cell were decreased, including 89 cases of pancytopenia (43.2%), 52 cases of WBC + PLT decrease (25.2%), 29 cases of RBC + PLT decrease (14.1%), and 36 cases of WBC + RBC decrease (17.5%); in 36% (116/322) of patients, single type blood cell decrease occurred, including 31 cases of PLT decrease (26.7%), 29 cases of WBC decrease (25%) and 56 cases of RBC decrease (48.3%). Of 227 routine bone marrow examinations, bone marrow hyperplasia was observed in 118 cases (52.0%), the remainder showed no hyperplasia. For the distinct scope and extent of peripheralblood cell decreases, preoperative blood component transfusions were carried out, then treated by surgery, after whole group splenectomy, the peripheral blood cell count was significantly higher (P<0.05).

CONCLUSIONS

Of portal hypertensive patients with splenomegaly and hypersplenism, 64% have simultaneous decrease in various blood cells, 36% have decrease in single type blood cells, 52% of patients have bone marrow hyperplasia. A splenectomy can significantly increase the reduction of peripheral blood cells.

Safety of epidural analgesia in the perioperative care of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy

BACKGROUND

The perioperative coagulopathy, hemodynamic instability, and infectious complications that may occur during cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has raised concerns about the safety of epidural analgesia in patients undergoing such procedures.

METHODS

We conducted a retrospective review of the perioperative anesthetic management of 215 adult patients who had undergone CRS with HIPEC with epidural analgesia. We reviewed epidural-related complications and analyzed the effect of early initiation of continuous epidural analgesia on estimated blood loss, intraoperative fluid administration, blood transfusion and vasopressor requirements, time to extubation, and length of stay.

RESULTS

No epidural hematomas or abscesses were reported. Two patients (0.9 %) had delays in epidural removal because of thrombocytopenia, and two had epidural-site erythema (0.9 %). The majority of postoperative epidural-related hypotensive episodes were successfully treated with fluid boluses. Early initiation of epidural analgesic infusions (before HIPEC) was associated with significantly less surgical blood loss and fluid requirements (P = 0.005 and 0.02, respectively). Pre-HIPEC initiation of epidural infusions was not associated with a statistically significant difference in the following: volume of blood transfused, intraoperative vasopressors use, time to extubation, and length of hospital stay.

CONCLUSIONS

With close hematologic monitoring and particular attention to sterility, epidural analgesia can be safely provided to patients undergoing CRS with HIPEC. Early initiation of continuous epidural infusions during surgery could lead to decreased blood loss and less intraoperative fluid administration. Prospective randomized studies are required to further investigate these potential benefits.

Epidural anaesthesia and analgesia for liver resection

Although epidural analgesia is routinely used in many institutions for patients undergoing hepatic resection, there are unresolved issues regarding its safety and efficacy in this setting. We performed a review of papers published in the area of anaesthesia and analgesia for liver resection surgery and selected four areas of current controversy for the focus of this review: the safety of epidural catheters with respect to postoperative coagulopathy, a common feature of this type of surgery; analgesic efficacy; associated peri-operative fluid administration; and the role of epidural analgesia in enhanced recovery protocols. In all four areas, issues are raised that question whether epidural anaesthesia is always the best choice for these patients. Unfortunately, the evidence available is insufficient to provide definitive answers, and it is clear that there are a number of areas of controversy that would benefit from high-quality clinical trials.

Comparing epidural analgesia and ON-Q infiltrating catheters for pain management after hepatic resection

BACKGROUND AND OBJECTIVES

Pain control after hepatic resection presents unique challenges as subcostal incisions, rib retraction, and diaphragmatic irritation can lead to significant pain. Both epidural analgesia and ON-Q catheters have been used for postoperative pain management after hepatic surgery, but to our knowledge have not been directly compared.

METHODS

The records of 143 patient between the ages 18 and 70 were reviewed who underwent hepatic resection by a single surgeon. Patients were categorized according to method of postoperative pain control. Average pain scores for both study groups were collected until POD#3.

RESULTS

Demographic data and the length of surgery were similar between the groups (all p>0.05). On the day of surgery and POD#1, average pain scores for the epidural group were lower than the ON-Q group (P<0.0001 and P=0.0008 respectively). There was no difference in pain scores on POD #2 (P=.2369) or POD #3 (P=0.2289).

CONCLUSIONS

Epidural analgesia provides superior pain control on the day of surgery and POD#1 when compared to On-Q catheter with IV PCA. There was no difference in pain scores on POD#2 or POD#3. Future prospective randomized trials comparing these analgesic methods will be required to further evaluate enhanced recovery after hepatic surgery.

Anesthetic considerations for the patient with liver disease

PURPOSE OF REVIEW

An increasing number of patients requiring surgery are presenting with chronic or end stage liver disease. The management of these patients demands anesthesiologists with in-depth knowledge of the consequences of hepatic dysfunction, the effects on other organs, the risk of surgery, and the impact of anesthesia.

RECENT FINDINGS

Chronic or end stage liver disease is associated with an increased risk of perioperative morbidity and mortality. It is essential to preoperatively assess possible hepatic encephalopathy, pleural effusions, hepatopulmonary syndrome, hepatopulmonary hypertension, hepatorenal syndrome, cirrhotic cardiomyopathy, and coagulation disorders. The application of two scoring systems, that is, Child-Turcotte-Pugh and model for end stage liver disease, helps to estimate the risk of surgery. The use of propofol is superior to benzodiazepines as intravenous narcotics. Although enflurane and halothane are discouraged for maintenance of anesthesia, all modern volatile anesthetics appear comparable with respect to outcome. Fentanyl, sufentanil, and remifentanil as opioids and cis-atracurium for relaxation may be the best choices in liver insufficency. Regional anesthesia is valuable for postoperative pain management.

SUMMARY

Current studies have employed different anesthetic approaches in the preoperative and intraoperative management in order to improve outcomes of patients with liver disease.

Postoperative management after hepatic resection

Hepatic resection has become the mainstay of treatment for both primary and certain secondary malignancies. Outcomes after hepatic resection have significantly improved with advances in surgical and anesthetic techniques and perioperative care. Metabolic and functional changes after hepatic resection are unique and cause significant challenges in management. In-depth understanding of hepatic physiology is essential to properly address the postoperative issues. Strategies implemented in the postoperative period to improve outcomes include adequate nutritional support, proper glycemic control, and interventions to reduce postoperative infectious complications among several others. This review article focuses on the major postoperative issues after hepatic resection and presents the current management.

Abnormal coagulation profile after hepatic resection: the effect of chronic hepatic disease and implications for epidural analgesia

STUDY OBJECTIVE

To evaluate the effect of chronic hepatic disease on postoperative coagulation.

DESIGN

Retrospective cohort study.

SETTING

Operating room with postoperative inpatient followup.

MEASUREMENTS

The records of 153 patients who underwent elective open hepatic resection were reviewed. The perioperative coagulation profile of each patient was assessed. The postoperative period was subdivided into the early [postoperative day (POD) 0-3] and late (POD 4 - POD 7) periods.

MAIN RESULTS

68 (44.4%) patients had chronic hepatic disease and 50 (32.7%) had cirrhosis. Eighty-four (54.9%) patients had an abnormal early postoperative coagulation profile and 46 (30.1%) had an abnormal late postoperative coagulation profile. The proportion of patients having an abnormal coagulation profile peaked on POD 2, at 39.2%. Only 5.3% of patients had an abnormal coagulation profile on POD 7. The independent predictors of abnormal early and late postoperative coagulation profiles were preexisting hepatic cirrhosis [early: odds ratio (OR) 3.73(1.49 - 9.29), late: OR 6.84(2.11 - 22.21)], abnormal preoperative coagulation profile [early: OR 9.68 (1.97 - 47.5), late: OR 11.71 (3.61- 38.02)], major hepatic resection [early: OR 4.15 (1.66 - 10.4), late: OR 5.43 (1.68 - 17.47)], and intraoperative blood loss.

CONCLUSIONS

An abnormal postoperative coagulation profile after hepatic surgery is common in a patient population with chronic hepatic disease.

[Anesthesia in the patient with impaired liver function]

We review information on impaired liver function, focusing on concepts relevant to anesthesia and postoperative recovery. The effects of impaired function are analyzed by systems of the body, with attention to the complications the patient with liver cirrhosis may develop according to type of surgery. Approaches to correcting coagulation disorders in the cirrhotic patient are particularly controversial because an increase in volume may be a factor in bleeding owing to increased portal venous pressure and imbalances in the factors that favor or inhibit coagulation. Perioperative morbidity and mortality correlate closely to Child-Pugh class and the score derived from the model for end-stage liver disease (MELD). Patients in Child class A are at moderate risk and surgery is therefore not contraindicated. Patients in Child class C or with a MELD score over 20, on the other hand, are at high risk and should not undergo elective surgical procedures. Abdominal surgery is generally considered to put patients with impaired liver function at high risk because it causes changes in hepatic blood flow and increases intraoperative bleeding because of high portal venous pressures.

Epidural analgesia provides better pain management after live liver donation: a retrospective study

Despite the increase in surgical volumes of live liver donation, there has been very little documentation of the postoperative pain experience. The primary aim of this study was to examine the difference in acute postoperative pain intensity and adverse effects between patients who received intravenous patient-controlled analgesia (IV PCA) or patient-controlled epidural analgesia (PCEA) for pain control after live liver donation surgery. A retrospective chart review was performed of 226 consecutive patients who underwent right living donor hepatic surgery at the Toronto General Hospital, Toronto, Canada. Patients who received as their primary postoperative analgesic modality IV PCA (n = 158) were compared to patients who received PCEA (n = 68). Demographic profiles for the 2 groups were similar with respect to age, sex, and body mass index at the time of surgery. For the first 3 postoperative days, pain intensity was significantly lower in patients who received epidural analgesia (P < 0.01). Clinically significant moderate pain (defined as a Numeric Rating Scale pain score >4) was reported more frequently in the IV PCA group (P < 0.05) along with increased sedation (P < 0.05). Pruritus was reported more frequently in the PCEA group of patients compared to the IV PCA group (P < 0.05). Significant between-group differences were not found for the incidence of postoperative vomiting, the time at which patients began fluid intake, the time to initial ambulation, or the length of hospital stay. In conclusion, epidural analgesia provides better postoperative pain relief, less sedation, but more pruritus than IV PCA after live liver donation.

Long-lasting analgesic effects of intraoperative thoracic epidural with bupivacaine for liver resection

OBJECTIVES

Continuous epidural analgesia may be considered in liver resection but is often avoided because of possible coagulopathies and the risk of epidural hematoma in the postoperative period. On the other hand, there is no coagulation defect during the surgery. Effective prevention of postoperative pain may require continuous sensory ablation throughout the surgery event.

METHODS

A prospective, randomized, double-blind study was conducted to evaluate the efficacy of intraoperative epidural anesthesia on postoperative morphine consumption via patient-controlled analgesia after liver surgery in 2 groups of patients. One group (epidural) received, intraoperatively, thoracic epidural bupivacaine perfusion (0.5% at 3 mL/hr) added to preoperative intrathecal morphine (0.5 mg) and fentanyl (15 microg). The other group (placebo) was administered the same intrathecal narcotics but with a sham epidural. Forty-four patients scheduled for major liver resection (> or =2 segments) were recruited. Patient-controlled analgesia morphine consumption, pain at rest and with movement, sedation, nausea, pruritus, and respiratory frequency were evaluated at 6, 9, 12, 18, 24, 36, and 48 hrs after intrathecal morphine injection.

RESULTS

Patients in the placebo group consumed twice as much morphine during each time interval than patients in the epidural group (at 48 hrs: 123 [SD, 46] vs 59 [SD, 25] mg; P < 0.0001). Pain evaluation on visual analog scale at rest and on movement was lower in the epidural group (P = 0.017 and P = 0.037).

CONCLUSION

Intraoperative thoracic epidural infusion of bupivacaine, added to intrathecal morphine, decreased postoperative morphine consumption with better pain relief compared with the placebo.