• Thomas A Aloia, Bradford J Kim, Yun Shin Segraves-Chun, Juan P Cata, Mark J Truty, Qiuling Shi, Alexander Holmes, Jose M Soliz, Keyuri U Popat, Thomas F Rahlfs, Jeffrey E Lee, Xin Shelley Wang, Jeffrey S Morris, Gottumukkala Vijaya N R VNR, and Jean-Nicolas Vauthey.
• *Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX †Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX ‡Department of Surgery, Mayo Clinic, Rochester, MN §Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX ¶Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX.
• Ann. Surg. 2017 Sep 1; 266 (3): 545-554.

ObjectivesThe primary objective of this randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient-controlled analgesia (IV-PCA) for pain control over the first 48 hours after hepatopancreatobiliary (HPB) surgery. Secondary endpoints were patient-reported outcomes, total narcotic utilization, and complications.BackgroundAlthough adequate postoperative pain control is critical to patient and surgeon success, the optimal analgesia regimen in HPB surgery remains controversial.MethodsUsing a 2.5:1 randomization strategy, 140 patients were randomized to TEA (N = 106) or intravenous patient-controlled analgesia (N = 34). Patient-reported pain was measured on a Likert scale (0-10) at standard time intervals. Cumulative pain area under the curve was determined using the trapezoidal method.ResultsBetween the study groups key demographic, comorbidity, clinical, and operative variables were equivalently distributed. The median area under the curve of the postoperative time 0- to 48-hour pain scores was lower in the TEA group (78.6 vs 105.2 pain-hours, P = 0.032) with a 35% reduction in patients experiencing ≥7/10 pain (43% vs 62%, P = 0.07). Patient-reported outcomes and total opiate use further supported the benefit of TEA on patient experience. Anesthesia-related events requiring change in analgesic therapy were comparable (12.2% vs 2.9%, respectively, P = 0.187). Grade 3 or higher surgical complications (6.6% vs 9.4%), median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the operating room (0.9% vs 3.1%) were similar (all P > 0.05). There were no mortalities in either group.ConclusionsIn major HPB surgery, TEA provides a superior patient experience through improved pain control and less narcotic use, without increased length of stay or complications.

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