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SRI Magazine 2018

SRI Magazine 2018

Local anesthetic after liver cancer surgery reduces opioid use

Patient-controlled analgesia also quickens recovery: study

The best treatment for liver cancer or other diseases of the liver is to remove all or part of the organ. Researchers have shown that rates of liver surgery in Canada are on the rise—about six per 100,000 adults. The procedure is effective but leaves people in pain, which can cause difficulty breathing, delayed mobility and longer hospital stays. Pain control is therefore critical to a good recovery.

Woman on hospital bed

Photo: Getty Images

One way of achieving this is through patient-controlled analgesia. Here, patients are given opioids intravenously; at the press of a button, they control how often they get the drug. Opioids like morphine help with pain, but there are drawbacks: nausea, vomiting, constipation, breathing problems and potential addiction. The other option is to give patients a preoperative epidural that works well but also carries risks, like low blood pressure, spinal infection and neurological damage. For these reasons epidurals are not a popular choice among doctors.

Dr. Paul Karanicolas, a Sunnybrook Research Institute surgeon-scientist in the Odette Cancer Research Program, led a clinical trial to determine if delivering a local anesthetic to numb pain nerves—a technique called medial open transversus abdominis plane (MOTAP) catheter analgesia—reduces opioid use. The study, which was published in the Annals of Surgery, included 153 patients who had open liver surgery at Sunnybrook and the University Health Network in Toronto, Canada.

At the end of the operation, doctors inserted catheters at the open surgical site. One-half of the patients were given ropivacaine, a local anesthetic, while the control arm received a saline solution. Patients in the MOTAP analgesia arm continued to receive ropivacaine for three days after the operation. Right after surgery, all of the patients were hooked up to a pump they controlled that dispensed opioid medication intravenously. The researchers studied how much opioids people used in the three days after the procedure.

On average, those who were given ropivacaine used 10 fewer milligrams of opioid 48 hours after surgery than those not given the anesthetic. Moreover, these patients reported feeling much less pain and, on the whole, were discharged one day earlier. Based on these results, Sunnybrook adopted MOTAP analgesia as the standard of care for patients undergoing open liver resection. The team has developed materials to help other surgeons learn the simple technique.