Improving pain control during transarterial chemoembolization for hepatocellular carcinoma performed under local anesthesia with multimodal analgesia

PURPOSE

The purpose of this study was to assess the performance of a reinforced analgesic protocol (RAP) on pain control in patients undergoing conventional trans-arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-one consecutive patients (57 men, 24 women) with a mean age of 69 ± 10 (standard deviation) years (age range: 49-92 years) underwent 103 cTACEs. Standard antalgic protocol (50 mg hydroxyzine, 10 mg oxycodone, 8 mg ondansetron, and lidocaine for local anesthesia) was prospectively compared to a RAP (standard + 40 mg 2-h infusion nefopam and 50 mg tramadol). The individual pain risk was stratified based on age, the presence of cirrhosis and alcoholic liver disease, and patients were assigned to a low-risk group (standard protocol) or high-risk group (RAP). The primary endpoint was severe periprocedural abdominal pain (SAP), defined as a visual analog scale score ≥30/100. A predefined intermediate analysis was performed to monitor the benefit-risk of the RAP. Based on the intermediate analysis, all patients were treated with the RAP.

RESULTS

The intermediate analysis performed after 52 cTACE showed that 2/17 (12%) high-risk patients (i.e., those receiving the RAP) experienced SAP compared to 15/35 (43%) low-risk patients (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.02-0.98; P = 0.03). Analysis of all procedures showed that 12/67 (18%) patients in cTACE receiving the RAP experienced SAP compared to 15/36 (42%) patients who did not receive it (OR = 3.27; 95% CI: 1.32-8.14; P = 0.01). There were no statistical differences in adverse events, particularly for nausea, between groups.

CONCLUSION

Reinforcing the analgesic protocol by combining non-opioid and opioid molecules reduces perioperative pain in patients undergoing cTACE for HCC.

Predictive factors of severe abdominal pain during and after transarterial chemoembolization for hepatocellular carcinoma

OBJECTIVES

To prospectively assess the frequency of severe abdominal pain during and after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) using the visual analog scale (VAS), and to identify predictive factors.

METHODS

Ninety-eight TACE performed in 80 patients (mean 65 ± 12 years old, 60 men) were consecutively and prospectively included. Abdominal pain was considered severe if the VAS ≥ 30/100 after treatment administration, or if opioid analgesic (grades 2-3) intake was required during hospitalization. Patient and tumor characteristics as well as technical factors associated with severe pain were identified by binary logistic regression.

RESULTS

The criterion for severe pain was met in 41/98 (42%) of procedures (peri-procedural pain 30/98 [31%] and opioid consumption during hospitalization 24/98 [25%]). Multivariate analysis identified age (odds ratio [OR] = 0.943 (95% confidence interval 0.895-0.994), p = 0.029), cirrhosis (OR = 0.284 (0.083-0.971), p = 0.045), and alcoholic liver disease (OR = 0.081 (0.010-0.659), p = 0.019) as negative predictive factors of severe abdominal pain. Severe abdominal pain occurred in or after 1/13 (8%), 8/34 (24%), 22/41 (54%), and 10/10 (100%) TACE sessions when none, one, two, and three of the protective factors were absent, respectively (p < 0.001). The area under the ROC curve of the combination of factors for the prediction of severe abdominal pain was 0.779 (CI 0.687-0.871).

CONCLUSION

Severe abdominal pain was frequent during and after TACE revealing a clinically relevant and underestimated problem. A predictive model based on three readily available clinical variables suggests that young patients without alcoholic liver disease or cirrhosis could benefit from reinforced analgesia.

KEY POINTS

• Severe abdominal pain occurs in 43% of TACE for HCC. • Younger age, absence of cirrhosis, and absence of alcoholic liver disease were identified as independent predictive factors of severe abdominal pain. • A simple combination of the three abovementioned features helped predict the occurrence of severe abdominal pain.