Randomized Prospective Trial of Epidural Analgesia after Open Hepatectomy

Objective: To evaluate whether patient-controlled epidural analgesia (PCEA) improves postoperative pain during ambulation following elective open hepatectomy. Background: Strategies to alleviate postoperative pain are a critical element of recovery after surgery. However, the optimal postoperative pain management strategy following open hepatectomy remains unclear. Methods: We conducted a prospective, non-blinded, randomized comparison of PCEA (intervention) vs. intravenous patient-controlled analgesia (IV PCA; control) for postoperative pain following elective open hepatectomy. The primary endpoint was pain during ambulation on postoperative day (POD) 2. The study was powered to detect a clinically significant 2-point difference on pain numeric rating scale (NRS). Secondary endpoints included pain at rest, morbidity, time to return of bowel function, and length of stay. Results: From 2015-2020, 231 patients were randomized (116 patients in the PCEA arm and 115 in the IV PCA arm). The incidence of epidural failure was 3% (n=4/116), with no epidural-related complications. Patients in the PCEA arm had a <2 point difference in NRS pain scores during ambulation on POD 2 vs. IV PCA (median 4.0 vs. 5.0, P <0.001). There was no difference in overall complications between the PCEA and IV PCA arms (33% vs. 40%, P =0.276). Secondary outcomes, including pain scores at rest, were similar between the study arms. Conclusions: PCEA was safe following open hepatectomy and was associated with a small difference in pain with activity on POD 2 that did not reach our pre-specified definition of clinical significance.