The use of prolonged epidural anesthesia in the perioperative period of major liver resections
Background. Major liver resections are the gold standard of medical care for patients with hepatocellular carcinoma. Such surgical procedure are traumatizing and cause massive nociceptive stimulation, intraoperative bleeding, total hypothermia. This requires using effective analgesic techniques and quality anesthesia control at all stages of anesthesia. The objective of the work was to improve the efficiency of anesthesia and to assess the adequacy of anesthesia during major liver resections in surgical oncology. Materials and methods. 121 patients scheduled for liver resections were enrolled in the clinical prospective randomized cohort study. All patients were randomized to one of three groups depending on the anesthesia and postoperative analgesia regimen. The groups were matched for age, sex, diagnosis, anthropometric indicators, nature and duration of operative intervention. The first group of patients (n = 41) underwent general anesthesia (total intravenous anesthesia (TIVA) with propofol and fentanyl) and opioid-based postoperative analgesia (morphine). The second group (n = 40) received thoracic epidural anesthesia (bupivacaine, no opioids) with TIVA (using propofol and fentanyl). The low-flow volatile regimen with sevoflurane combined with prolonged thoracic epidural bupivacaine analgesia was administered to the third group of patients (n = 40). Thromboprophylaxis with anticoagulants (bemiparin and enoxaparin) was started the day before liver resection and lasted for 10–14 days. The comparative analysis of efficacy and safety of described regimens has been made with important indicators of central hemodynamics, cardiac rhythm variability, serum cortisol concentration, glycemia, postoperative morbidity, clinical indicators of postoperative recovery period. Duration of mandatory mechanical ventilation, pain intensity by visual analog scale (VAS), level of sedation by the Richmond agitation-sedation scale (RASS), the duration of postoperative ileus, length of hospital stay, the incidence of complications were registered in the early postoperative period. Analyzing the research results, methods of biostatistics were used. Results. Initial parameters of central hemodynamics, heart rhythm variability, glycemia, serum cortisol were not statistically different in all three groups. Sympathetic surge was maximally presented in patients of the group 1 at all stages of liver resection. Parameters of mean arterial pressure, heart rate, total peripheral vascular resistance, heart rate variability (LF/HF), glycemia and cortisol were increased in the first group. During the early postoperative period, the quality of anesthesia was higher in patients with epidural anesthesia compared to opioid anesthesia. Pain intensity (VAS), hyperglycemia and level of sedation (RASS) were more significant in patients of the group 1 as compared to the groups 2 and 3. The use of epidural anesthesia in patients of the groups 2 and 3 compared with the group 1was found to reduce opioid and muscle relaxant consumption during surgery, to decrease the duration of mandatory lung ventilation, to start postoperative enteral feeding and to activate patients earlier, to reduce length of hospital stay and morbidity rate. Pleural effusions after liver resection were diagnosed in 2 patients (4.9 ± 3.4 %) of the group 1, one patient (2.5 ± 2.5 %) of the group 2 (p = 0.37), and subphrenic abscesses — in 6 patients (14.6 ± 5.5 %) of the group 1 (p = 0.002). Conclusions. Implementation of low flow sevoflurane anaesthesia combined with prolonged thoracic epidural analgesia prevents sympathetic surge, suppresses surgical stress response and improves recovery after major liver resections in surgical oncology.
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