Intravenous Patient-controlled Analgesia Versus Thoracic Epidural Analgesia After Open Liver Surgery: A Prospective, Randomized, Controlled, Noninferiority Trial

Ann Surg. 2019 Aug;270(2):193-199. doi: 10.1097/SLA.0000000000003209.


Objective: We conducted a randomized, controlled, noninferiority trial to investigate if intravenous, multimodal, patient-controlled analgesia (IV-PCA) could be noninferior to multimodal thoracic epidural analgesia (TEA) in patients undergoing open liver surgery.

Summary background data: The increasing use of minimally invasive techniques and fast track protocols have questioned the position of epidural analgesia as the optimal method of pain management after abdominal surgery.

Methods: Patients operated with open liver resection between February 2012 and February 2016 were randomly assigned to receive either IV-PCA enhanced with ketorolac/diclofenac (IV-PCA, n = 66) or TEA (n = 77) within an enhanced recovery after surgery protocol. Noninferiority would be declared if the mean pain score on the numeric rating scale (NRS) for postoperative days (PODs) 0 to 5 in the IV-PCA group was no worse than the mean pain score in the TEA group by a margin of <1 point on an 11-point scale (0-10).

Results: The primary endpoint, mean NRS pain score was 1.7 in the IV-PCA group and 1.6 in the TEA group, establishing noninferiority. Pain scores were lower in the TEA group on PODs 0 and 1, but higher or equal on PODs 2 and 5. Postoperative hospital stay was significantly shorter for patients in the IV-PCA group (74 vs 104 h, P < 0.001). The total opioid consumption during the first 3 days was significantly lower in the IV-PCA group.

Conclusions: IV-PCA was noninferior to TEA for the treatment of postoperative pain in patients undergoing open liver resection.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Analgesia, Epidural* / methods
  • Analgesia, Patient-Controlled* / methods
  • Analgesics, Opioid / administration & dosage*
  • Anti-Inflammatory Agents, Non-Steroidal / administration & dosage*
  • Colorectal Neoplasms / pathology
  • Diclofenac / administration & dosage
  • Equivalence Trials as Topic
  • Hepatectomy / adverse effects*
  • Humans
  • Infusions, Intravenous
  • Ketorolac / administration & dosage
  • Length of Stay
  • Liver Neoplasms / secondary
  • Liver Neoplasms / surgery
  • Pain, Postoperative / prevention & control*
  • Prospective Studies


  • Analgesics, Opioid
  • Anti-Inflammatory Agents, Non-Steroidal
  • Diclofenac
  • Ketorolac