No abstract

No abstract

SummaryAlthough 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. Epidural anaesthesia is a technique that can provide high-quality analgesia and, by reducing cardiovascular and respiratory complications, support early mobilisation after surgery [1]. It has been successfully used as part of multimodal packages for delivery of enhanced recovery, including recovery of patients undergoing liver resection [2]. Although thoracic epidural anaesthesia and analgesia are commonly used for liver resection [3-6], there are concerns over its safety in this specific patient population. Complications associated with epidural catheters are uncommon, but include epidural haematomas, epidural abscesses or spinal cord injury [7,8]. Following hepatic resection, haemostatic disorders do occur, despite completely normal pre-operative coagulation function, and this may increase the risk of epidural haematoma [6,9]. It is controversial as to whether the benefits of thoracic epidural anaesthesia and analgesia, including excellent analgesia, decreased incidence of pulmonary complications and reduced duration of ileus, outweigh its potential risks such as epidural haematoma and increased administration of intravenous fluids [7,[10][11][12][13]. This review focuses on the safety and analgesic efficacy of the use of this technique in patients undergoing liver resection and also discusses the risk-benefit ratio of its use in the context of accelerated and enhanced recovery programmes. MethodsBoth MEDLINE and the Cochrane Library were searched for papers published in English on anaesthesia for liver surgery from 1