Epidural analgesia versus fascial plane blocks: a critical appraisal in the context of hepatopancreaticobiliary enhanced recovery pathways

Abstract

Background: Epidural analgesia (EA) is an effective method to both control post-operative pain and reduce perioperative complications after major abdominal surgery. However, with the introduction of Enhanced Recovery (ER) pathways, potential side effects associated with EA such as hypotension and oliguria are in conflict with core ER endpoints. Novel methods, collectively named facial plane blocks (FPB), offer a promising alternative, providing effective pain control while negating unwanted side effects associated with EA. This study compares EA to FPB in hepatopancreatobiliary surgery in an established ER practice. Methods: Data for 34 patients who underwent open liver, pancreas, or extrahepatic biliary surgery were prospectively acquired and retrospectively analyzed. Patients were randomly assigned into two arms, EA and FPB. The FPB group included three methods: transversus abdominis, quadratus lumborum, and erector spinae blocks. The route was based on the anesthesia provider’s preference. EA and FBP groups were compared on continuous variables (e.g. age, BMI) with Wilcoxon-Mann-Whitney test, binary variables (e.g. sex) with Fisher’s exact test, and categorical variables with >2 categories (e.g. ethnicity) were compared with chi-squared test. Results: 19 patients received EA and 15 FPB. There were no differences regarding age, sex, ethnicity, indication for surgery (benign vs. malignant), ECOG performance status and BMI between EA and FPB groups. The pre-incision anesthesia preparation time (73 vs 50 min, for the EA and FPB respectively; p < 0.001) and procedure time for the analgesia intervention (21 vs 13 min; p = 0.02) were both shorter in the FPB arm. Mean intraoperative intravenous colloid infusion was 296ml in the EA group vs 95ml in the FPB group (p = 0.03). Post-operatively, arterial hypotension (systolic blood pressure < 90 mmHg) was observed in 54% of EA vs 8% of the FPB patients (p = 0.03). FPB was also favorable in regards to Foley catheter removal and time to first ambulation, both being achieved 24 hours earlier. There was no statistically significant differences in pain scores between the two arms. Post-operative complications were not noted to differ between the two groups. Conclusion: In major open abdominal operations, there were no significant differences in pain scores or complications between FPB and EA. Our data suggest superiority of the former in several key ERAS endpoint domains. These outcomes will be further validated in a prospective randomized fashion. Of additional interest are the economic implications of FPB, potentially positively affecting operating room time and utilization.