Hepatic resection is associated with reduced postoperative opioid requirement

Current Practices and Recent Advances in Perioperative Pain Management for Liver Transplantation Living Donors and Recipients

Analgesia in liver transplantation patients has been traditionally considered a secondary priority where perioperative management principally focused on survival rates in these critically ill patients. With recent advancements in both surgical and medical management, posttransplant survival rates have steadily improved. Outcome measurements are no longer limited to short-term mortality rates and hospital length of stay but are also measured by patient-centered outcomes, such as pain control and quality of life. As living donor liver transplantation has increased access to transplantation, it has also added a different patient population to manage in the perioperative period. For healthy patients undergoing living donor hepatectomies, it is important to reduce the impact of the surgery with proper perioperative pain management. We performed a literature search for articles related to perioperative pain management for liver transplantation living donors and recipients to identify current practices and recent advances. Neuraxial techniques, peripheral nerve blocks, and enteral and parenteral medications were all found to be feasible analgesia modalities for patients undergoing either liver transplant or donor hepatectomy. Patients may also benefit from nonpharmacological interventions and preoperative counseling. No particular perioperative analgesic modality was deemed superior to any other. For liver transplant living donors and recipients, perioperative pain management should emphasize the application of sustainable patient-centered pain control protocols.

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.

Comparison of postoperative analgesic effects of erector spinae plane block and quadratus lumborum block in laparoscopic liver resection: study protocol for a randomized controlled trial

BACKGROUND

Compared with open surgery, laparoscopic liver resection is a minimally invasive surgical technique. However, a number of patients experience moderate-to-severe postoperative pain after laparoscopic liver resection. This study aims to compare the postoperative analgesic effects of erector spinae plane block (ESPB) and quadratus lumborum block (QLB) in patients undergoing laparoscopic liver resection.

METHODS

One hundred and fourteen patients undergoing laparoscopic liver resection will be randomly allocated to three groups (control, ESPB, or QLB) in a 1:1:1 ratio. In the control group, participants will receive systemic analgesia consisting of regular NSAIDs and fentanyl-based patient-controlled analgesia (PCA) according to the institutional postoperative analgesia protocol. In the two experimental groups (ESPB or QLB group), the participants will receive preoperative bilateral ESPB or bilateral QLB in addition to systemic analgesia according to the institutional protocol. ESPB will be performed at the 8th thoracic vertebra level with ultrasound guidance before surgery. QLB will be performed in the supine position on the posterior plane of the quadratus lumborum with ultrasound guidance before surgery. The primary outcome is cumulative opioid consumption 24 h after surgery. Secondary outcomes are cumulative opioid consumption, pain severity, opioid-related adverse events, and block-related adverse events at predetermined time points (24, 48, and 72 h after surgery). Differences in plasma ropivacaine concentrations in the ESPB and QLB groups would be investigated, and the quality of postoperative recovery among the groups will be compared.

DISCUSSION

This study will reveal the usefulness of ESPB and QLB in terms of postoperative analgesic efficacy and safety in patients undergoing laparoscopic liver resection. Additionally, the study results will provide information on the analgesic superiority of ESPB versus QLB in the same population.

TRIAL REGISTRATION

Prospectively registered with the Clinical Research Information Service on August 3, 2022; KCT0007599.

Future liver remnant volume is associated with postoperative fentanyl consumption following open donor hepatectomy: a retrospective multivariate analysis

PURPOSE

Liver resection has a risk of postoperative hepatic dysfunction, including drug metabolism. Since fentanyl is primarily metabolized in the liver, liver resection requires exercising caution against fentanyl overdose in postoperative analgesia. The rationale for dose adjustment of fentanyl in the preoperative prescription for patients undergoing liver resection remains unclear. We examined whether postoperative fentanyl consumption is associated with the future liver remnant after liver resection and investigated factors influencing fentanyl consumption.

METHODS

In this retrospective study, 89 living liver donors undergoing open liver resection received intravenous patient-controlled analgesia with fentanyl 2 mg with thoracic epidural analgesia. The primary outcome was postoperative hourly consumption of intravenous patient-controlled analgesia with fentanyl. Future liver remnant volume (ml) and the ratio of future liver remnant volume to whole liver volume (%) were estimated by computed tomography volumetry and compared to determine which correlated more strongly with fentanyl hourly consumption. Multivariable analysis identified independent factors affecting fentanyl consumption, with adjustments for patient characteristics and intravenous patient-controlled analgesia setting.

RESULTS

Future liver remnant volume (ml) was significantly correlated more strongly than the ratio of future liver remnant (%) with postoperative fentanyl consumption (r = 0.53 vs. 0.36, p < 0.001). Larger future liver remnant volume (β = 0.25, p = 0.006) and age < 45 years (β = 0.24, p = 0.009) were independently associated with higher fentanyl consumption, while sex and weight were not.

CONCLUSIONS

Future liver remnant volume was significantly associated with postoperative fentanyl consumption. Smaller remnant liver volume and older age (≥ 45 years) were independent factors reducing postoperative fentanyl consumption in patients undergoing open donor hepatectomy.