Background and objectives Effective pain control improves postoperative rehabilitation and enhances recovery. The aim of this review was to evaluate the available evidence and to develop recommendations for optimal pain management after open liver resection using Procedure-Specific Postoperative Pain Management (PROSPECT) methodology.
Strategy and selection criteria Randomized controlled trials (RCTs) published in the English language from January 2010 to October 2019 assessing pain after liver resection using analgesic, anesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane databases.
Results Of 121 eligible studies identified, 31 RCTs and 3 systematic reviews met the inclusion criteria. Preoperative and intraoperative interventions that improved postoperative pain relief were non-steroidal anti-inflammatory drugs, continuous thoracic epidural analgesia, and subcostal transversus abdominis plane (TAP) blocks. Limited procedure-specific evidence was found for intravenous dexmedetomidine, intravenous magnesium, intrathecal morphine, quadratus lumborum blocks, paravertebral nerve blocks, continuous local anesthetic wound infiltration and postoperative interpleural local anesthesia. No evidence was found for intravenous lidocaine, ketamine, dexamethasone and gabapentinoids.
Conclusions Based on the results of this review, we suggest an analgesic strategy for open liver resection, including acetaminophen and non-steroidal anti-inflammatory drugs, combined with thoracic epidural analgesia or bilateral oblique subcostal TAP blocks. Systemic opioids should be considered as rescue analgesics. Further high-quality RCTs are needed to confirm and clarify the efficacy of the recommended analgesic regimen in the context of an enhanced recovery program.
- pain management
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AD and PH are joint first authors.
AD and PH contributed equally.
Contributors AD and PH conducted the article search, selected the studies based on the procedure-specific postoperative pain management methodology, collected and organized the data, and wrote the manuscript; equally contributed and therefore shared first authorship. PL, HB, SF, EMP-Z, GJ and MVdV helped establish the guidelines based on the data presented by AD and PH and helped improve the manuscript.
Funding Procedure-Specific Postoperative Pain Management (PROSPECT) is supported by an unrestricted grant from the European Society of Regional Anaesthesia and Pain Therapy. In the past, PROSPECT has received unrestricted grants from Pfizer Inc., New York, New York, USA, and Grunenthal, Aachen, Germany.
Competing interests GJ has received honoraria from Baxter and Pacira Pharmaceuticals. FB has received honoraria from Pfizer, The Medicine Company, Abbott France, Nordic Pharma France, Heron therapeutics, AMBU and Grunenthal. MVdV has received honoraria from Sintetica, Grunenthal, Vifor Pharma, MSD, Nordic Pharma, Janssen Pharmaceuticals, Heron Therapeutics and Aguettant. EP-Z has received honoraria form Mundipharma, Grunenthal, MSD, Janssen-Cilag GmbH, Fresenius Kabi and AcelRx.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. The authors declare that the data supporting the findings of this study are available within the article.
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