Abstract
Background: The existing recommendations for after open liver surgery, published in 2019, contains limited evidence on the use of regional analgesia techniques. The aim of this systematic review is to summarize available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery. Methods: The PUBMED and EMBASE registries were used for the literature search to identify suitable studies. Keywords for the literature search were selected, with the authors’ agreement, using the PICOS approach: participants, interventions, comparisons, outcomes, and study design. Results: The literature search led to the retrieval of a total of 800 studies. A total of 36 studies including 25 RCTs, 5 prospective observational, and 7 retrospective observational studies were selected as suitable for this systematic review. Conclusions: The current evidence suggests that, in these patients, optimal postoperative pain management should rely on using a “blended approach” which includes the use of systemic opioids and the infusion of NSAIDs along with regional techniques. This approach warrants the highest efficacy in terms of pain prevention, including the lower incretion of postoperative “stress hormones”, and fewer side effects. Furthermore, concerns about the potential for the increased risk of wound infection related to the use of regional techniques have been ruled out.
Highlights
Pain after open liver surgery can be attributed to two major mechanisms: peripheral nociceptors stimulation and visceral origin transmitted by sympathetic nerves [1,2,3]
The efficacy of a transversus abdominis plane block (TAP) block in preventing postoperative pain after open liver surgery was tested in nine studies, which included a total of 816 patients: two compared to neuraxial analgesia (2 RO), two to placebo (2 randomized controlled trials (RCTs)), three to systemic opioids (2 RCTs and 1 RO), one assessed the combination with non-steroidal anti-inflammatory drugs (NSAIDs)-parecoxib-(RCT) and one to WI (RCT) [31,32,33,34,35,36,51,52,53]
In these patients, optimal postoperative pain management should rely on using a “blended approach” that includes the use of systemic opioids and NSAID infusion along with regional techniques (WI, TAP blocks, thoracic epidural analgesia (TEA), intrathecal morphine (ITM), paravertebral nerve block (PVB), quadratus lumborum block (QLB))
Summary
Pain after open liver surgery can be attributed to two major mechanisms: peripheral nociceptors stimulation (induced by subcostal incision, rib retraction, diaphragmatic irritation, etc.) and visceral origin transmitted by sympathetic nerves [1,2,3]. Used modalities for postoperative pain control are systemic intravenous analgesics, epidural analgesia, and peripheral nerve blocks [11,12]. Epidural analgesia might provide improved pain control, but in the specific setting of open liver surgery, may potentially challenge and have harmful drawbacks as a sympathetic blockade (with hypotension, bradycardia) and intraoperative fluid overload arises and its use might be limited because of the possible perioperative coagulopathy [13,15,16,17,18]. The aim of this systematic review (SR) is to summarize the available clinical evidence, published after September 2013, on systemic or blended postoperative analgesia for the prevention or treatment of postoperative pain after open liver surgery
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