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

Abstract

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.

Pain Management After Open Liver Resection: Epidural Analgesia Versus Ultrasound-Guided Erector Spinae Plane Block

“…Lower opioid use and lower pain scores with TEA may be due to greater potential for the sympathetic blockade, which may reduce visceral pain resulting during hepatectomy. Somatic and visceral pain during hepatic resection is related to a variety of factors including an incision through the skin, soft tissue, and muscle, rib retraction, as well as diaphragmatic and peritoneal irritation [5]. Somatic pain typically constitutes approximately 70-75% of pain and lasts about 72 hours following open surgery, while visceral pain is typically acute and more intense, lasting for 24-36 hours.…”

“…Open liver resection surgery is associated with intraoperative blood loss, hypotension, coagulopathy, pulmonary complications, liver impairment, and renal impairment, making perioperative pain management challenging [4]. Multimodal analgesic strategies employing regional techniques decrease postoperative pain and opioid consumption following liver resections [5]. Thoracic epidural analgesia (TEA) is considered the 'gold standard' for open thoracic and abdominal surgical procedures [1,2].…”

Continuous Erector Spinae Plane Block Using Programmed Intermittent Bolus Regimen versus Intravenous Patient-Controlled Opioid Analgesia Within an Enhanced Recovery Program After Open Liver Resection in Patients with Coagulation Disorder: A Randomized, Controlled, Non-Inferiority Trial

“…Patient-controlled intravenous analgesia with opioids is a conventional acute pain therapy with established analgesic efficacy after open hepatectomy. 17 , 18 We, therefore, performed a noninferiority trial to explore whether a safe and easily performed regional analgesia method, ie, continuous ESPB, would provide noninferior pain therapy to opioid PCIA after open liver resection.…”

“…The somatic pain caused by the subcostal incision is mainly transmitted via the intercostal nerves T6 to T10, while the visceral pain comes from the coeliac plexus. 18 Although the mechanism of ESPB is controversial, anatomical and clinical studies have suggested that local anesthetic injected into the ESP could spread into the thoracic paravertebral space and proximal intercostal spaces where it acts on the ventral rami of the spinal nerves and intercostal nerves to provide both visceral and somatic analgesia. 19 , 20 However, clinical evidence supports that the patterns of cutaneous sensory blockade often underrepresent the analgesia observed with FPB.…”

Race, ethnicity, and the use of regional anesthesia in cancer patients undergoing open abdominal surgery: A single-center retrospective cohort study

“…The inclusion of regional anesthesia in perioperative pain control regimens has been shown to be superior to opioid or non-opioid analgesic modalities alone (4)(5)(6). However, some studies have shown ethnic-based disparities in the use of regional anesthesia (1,(7)(8)(9)(10)(11).…”