A randomized controlled trial of postoperative thoracic epidural analgesia versus intravenous patient controlled analgesia after major HPB surgery

Abstract

Background: The optimal postoperative analgesic regimen for 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. 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, operative time, EBL and postoperative drain placement were equivalent. The median AUC of the postoperative 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 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. Conclusion: In major HPB surgery, TEA provides a superior patient experience through improved pain control without increased length of stay or complications.