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A Randomized Controlled Trial of Postoperative Thoracic Epidural Analgesia Versus Intravenous Patient Controlled Analgesia after Major Hepatopancreatobiliary Surgery
Thomas A. Aloia*1, Bradford J. Kim1, Yun Shin Chun*1, Juan P. Cata*1, Mark J. Truty*2, Alexander Holmes*1, Jose M. Soliz*1, Keyuri U. Popat*1, Debra L. Kennamer*1, Thomas F. Rahlfs*1, Jeffrey E. Lee1, Vijaya Gottumukkala*1, Jean-Nicolas Vauthey1
1University of Texas MD Anderson Cancer Center, Houston, TX;2Mayo Clinic, Rochester, MN

OBJECTIVE(S): The optimal postoperative analgesic regimen for hepatopancreatobiliary (HPB) surgery patients remains controversial. The primary objective of this single-center randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient controlled analgesia (PCA) for adequacy of pain control over the first 48 hours after surgery. Secondary endpoints were anesthetic and surgical complications.
METHODS: Using a 2.5:1 randomization strategy, 140 patients undergoing HPB resections were randomized to TEA (N=106) or PCA (N=34). Patient-reported pain was measured on a Likert scale (0-10) at standard time intervals. Cumulative pain area under the curve (AUC) was determined using the trapezoidal method.
RESULTS: Demographic, comorbidity, clinical and operative variables, including incision type and resection magnitude were equivalent. Likewise, estimated blood loss, operative time, and postoperative drain placement were similar. The median AUC of the postoperative time 0 to 48 hour pain scores was significantly lower in the TEA group (81.15 vs 109.6, p=0.029) with a 35% reduction in patients with pain episodes >=7/10 (43% vs 66%, p=0.05). Anesthesia related events requiring change in analgesic therapy were comparable (10.4% vs 3.1%, p=0.29). Grade >=3 surgical complications occurred in 7 TEA group patients (6.6%) and 3 PCA group patients (9.4%, p=0.7). Median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the OR (0.9 vs 3.1%) were similar (all p>0.05). There were no mortalities in either group.
CONCLUSIONS: In major HPB surgery, TEA provides a superior patient experience through improved pain control without increased length of stay or complications.

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