Open Liver Resection 2019

Open liver resection-specific evidence

Data table: NSAIDs/COX-2-selective inhibitors for pain management after open liver resection

Arguments for…

• Two placebo-controlled RCTs reported significant pain relief and opioid sparing with pre- and post-operative administration of parecoxib, with rescue analgesia provided by IV-PCA opioid (Wang 2020; Chen 2017).
• Another RCT compared a combination of parecoxib with TAP blocks with placebo and no TAP blocks and reported significantly lower pain scores on postoperative days 1 and 2 in the study group (Qiao 2019).
• A placebo-controlled RCT evaluated the analgesic effects of IV ketorolac initiated postoperatively for 48 hours, and found lower pain scores and an opioid-sparing effect from 6 hours until 36 hours after surgery (Yassen 2012).
• Paracetamol, as co-analgesic, was not used in any of these studies.

PROSPECT Recommendations

• Paracetamol and an NSAID are recommended, unless contraindicated, administered either pre-operatively or intra-operatively and continued postoperatively.
  • Analgesic efficacy was shown for NSAIDs as basic analgesics administered pre-operatively or intra-operatively and continued postoperatively on a “round-the-clock” or scheduled basis.
  • No study investigated the analgesic efficacy of paracetamol in liver resection, although given its relative safe profile and the few side effects, it is considered as basic (i.e. first line) analgesic according to the PROSPECT methodology (Joshi 2019). Paracetamol was used as basic analgesic in several RCTs included in this review.
  • Risk factors for hepatotoxicity that should be considered before using paracetamol include liver disease, age, malnutrition and intra-operative liver ischaemia. The altered pharmacokinetics in patients with liver disease or after major liver resections might influence the paracetamol dose (Galinski 2006; Rudin 2007). Overall, there is a low risk for paracetamol toxicity after liver resection, and therefore, it is recommended as basic analgesic.

See Pre-/Intra-operative Interventions:

• Subcostal transversus abdominis plane (TAP) blocks
• Epidural analgesia

PROSPECT Recommendations

• A catheter-based regional analgesia technique, as chosen in the pre-operative/ intra-operative period, is recommended.

Open liver resection-specific evidence

Data table: Interpleural analgesia for pain management after open liver resection

Arguments for…

• Interpleural analgesia with levobupivacaine infusion reduced resting pain scores at 6 hours and movement-evoked pain for 24 after surgery compared with IV-PCA morphine (Weinberg 2010). Baseline analgesia included paracetamol in both the groups.

PROSPECT Recommendations

• Postoperative interpleural analgesia is not recommended due to limited procedure-specific evidence.