LAUSR

G ood analgesia is a goal after major surgery. This does not necessarily equate to a pain score of zero, but does mean analgesia that provides well-tolerated pain relief and allows for early mobilization. Many different modalities of postoperative pain management have been studied with multiple meta-analyses and clinical trials having been published. This is especially the case for open liver surgery, which is one of the more challenging surgeries for providing good postoperative analgesia. Different and sometimes contradictory results on the optimal analgesic technique may be found in these manuscripts, especially in regard to the use of thoracic epidural analgesia. Two manuscripts in this month’s Annals of Surgery exemplify the different findings, but also demonstrate how different centers may have different results. There is no doubt that many factors affect the success of thoracic epidural analgesia and the reduction of complications. The most important factor is the technical expertise of the anesthesiologist, but the postoperative management by the perioperative team is also a critical factor for early mobilization and return to normal function. The concerns that many physicians have with the management of epidural anesthesia for open liver surgery include the increased risk of a neuraxial hematoma resulting from a postoperative coagulopathy. In some centers this has resulted in the reluctance to using the modality and in others to withholding of venous thromboembolism (VTE) prophylaxis until the prothrombin time-derived international normalized ratio (PT-INR) has returned to less than 1.5. This, in some centers leads to the administration of fresh frozen plasma to correct the PT-INR. A review of the National Surgical Quality Improvement Program data for extended hepatic resections, the VTE rate has been reported as high as 5.8%. This exceeds the rate for most major abdominal surgeries including colectomy. It has now been well established that many of these patients with an increased PT-INR have normal or increased coagulable states and do need VTE protection. The success of epidural anesthesia to provide optimal pain management for open liver surgery requires the formation of a surgical team. An experienced team approach leads to greater success, including the reduction of complications, early mobilization and discharge home, and thereby increased patient safety. Postoperative analgesia still continues to be inadequately managed in many centers. However, Kehlet and Wilmore, have developed enhanced recovery pathways (ERPs) after surgery that have resulted in early mobility and discharge, good pain management with multimodal analgesia and reduced or opioid-free therapy, and reduced morbidity and mortality. Protocols that promote ERPs have become more frequently used and the evidence to support these protocols is getting stronger. Randomized clinical trials have shown that ERPs are effective as long as each member of the perioperative team is well versed in the protocols, carries them out effectively, and the data are collected and monitored. These protocols are not just reliant on 1 anesthetic technique but rather rely on the experience of all team participants to be expert in the techniques used. The team must consist of the surgeon, anesthesiologist, perioperative nurses, pharmacy staff, physical and respiratory therapists, and the patient, together with a coordinator who collects the data and helps to demonstrate what is or is not working. This will enable the team and the hospital to track progress, provide education, and more importantly to learn where they are having success and what areas need improvement. The surgical team should have regular meetings to discuss patient management. Local expertise at each center will dictate if thoracic epidural analgesia is used or if transversus abdominis plane (TAP) nerve blocks along with rectus sheath blocks are employed, or some other pain management modality. What is required is that evidence-based data demonstrates that the technique is effective and that a reliable surgical team has been put in place. Centers where thoracic epidurals have a high complication rate, such as a significant failure rate, neuraxial hematomas, hypotension, and increased fluid administration, may be better served using a different modality.