• Michael C Grant, Philip M Sommer, Cathy He, Sylvia Li, Andrew J Page, Alexander B Stone, Deborah Hobson, Elizabeth Wick, and Christopher L Wu.
• From the *Department of Anesthesiology/Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD; †Department of Surgery, Piedmont Healthcare, Atlanta, GA; ‡Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, MD; and §Department of Surgery University of California, San Francisco, CA.
• Reg Anesth Pain Med. 2017 Jul 1; 42 (4): 451-457.

BackgroundEnhanced recovery after surgery (ERAS) pathways are designed to restore baseline physiology, mitigate surgical stressors, and hasten recovery. Paramount to this approach is optimal pain control through multimodal analgesia and limiting reliance on opioid-based medications. Recent studies have fostered growing controversy surrounding the use of epidural analgesia in the ERAS setting, especially for higher-risk procedures. We examine the analgesic end points associated with the use of epidural within the ERAS framework for open hepatectomy.MethodsFrom November 2013 through March 2016, postoperative analgesic end points including daily morphine equivalent administration and self-reported pain scores were prospectively collected and analyzed for 180 consecutive patients scheduled for open hepatectomy. Patients whose surgeries performed prior to July 2014 were managed using traditional strategy (pre-ERAS, n = 60), and those after July 1 underwent a comprehensive perioperative ERAS pathway (ERAS, n = 120).ResultsPatients managed using the ERAS pathway had a significant reduction in morphine equivalent requirements at 24 hours (median, 10.0 vs 116.0 mg; P < 0.001), 48 hours (median, 10.1 vs 85.4 mg; P < 0.001), and 72 hours (median, 2.5 vs 60.0 mg; P < 0.001) compared with pre-ERAS counterparts with a reduction in average pain scores at 24 hours (numeric pain rating scale, 4.1 ± 1.6 vs 5.1 ± 1.8) and similar scores at other time points. Within ERAS, patients who received epidural (n = 87) required significantly less morphine equivalents at 24 hours (median, 2.7 vs 65.0 mg; P < 0.001) and 48 hours (median, 8.0 vs 50.0 mg; P < 0.001) but not at 72 hours (median, 1.3 vs 4.5 mg; P = 0.56), as well as improved pain scores at 24 hours (visual analog scale score, 3.8 ± 1.3 vs 5.0 ± 1.8; P < 0.001) and 48 hours (3.4 ± 1.8 vs 4.7 ± 1.9; P = 0.001) compared with those who did not receive epidural (n = 33). Other associated postoperative end points including provision of fluids, rates of clinically significant hypotension, and lengths of stay between epidural and nonepidural groups were similar.ConclusionsA novel ERAS protocol for open hepatectomy successfully reduced reliance on perioperative opioids without expensing adequate analgesia compared with traditional care. Patients within ERAS benefitted from application of epidural, which further reduced opioid requirements and optimized pain control without increasing complication rates. Epidurals should remain an integral part of ERAS protocols for liver resection surgery.

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