thoracic epidural analgesia or four-quadrant transversus abdominus plane block in reducing pain in patients undergoing liver surgery

Conditions: Liver and Intrahepatic Bile Duct Disorder

Summary: this phase iii trial studies how well thoracic epidural analgesia or four-quadrant transversus abdominus plane block works in reducing pain in patients undergoing liver surgery. it is not yet known whether thoracic epidural analgesia or four-quadrant transversus abdominus plane block may help people to recover more completely and more quickly after surgery.

primary objective: i. to compare length of hospital stay between patients treated with thoracic epidural analgesia (tea) versus (vs.) pre-incision ultrasound-guided, four-quadrant transversus abdominus plane (tap) block after open liver resection within an enhanced recovery program. secondary objectives: i. to compare the area under the curve of early (0-48 hour) post-operative pain scores and number of patients who experience severe postoperative pain between the tea and tap groups. ii. to compare anesthetic-related complication rates and need to change modalities between tea and tap groups. iii. to compare surgery-related complications (including 30-day readmission and 90-day mortality rates) between tea and tap groups. iv. to compare return to baseline symptom burden, functional and cognitive status between tea and tap groups. outline: patients are randomized into 1 of 2 arms. arm i: patients undergo placement of thoracic epidural catheter before surgery. patients receive hydromorphone hydrochloride and bupivacaine via thoracic epidural catheter every 10 minutes or 3 hours as needed. patients may receive fentanyl and bupivacaine or plain bupivacaine via thoracic epidural catheter. arm ii: patients undergo placement of ultrasound-guided, four-quadrant transversus abdominus plane block. patients receive plain bupivacaine and liposomal bupivacaine via tap block.

Eligibility criteria:
inclusion criteria: * patients undergoing open liver resection without bowel resection/anastomosis for malignancy at md anderson cancer center * patients must sign a study-specific consent form * platelets \>= 100,000/ml (within 30 days of surgery) * international normalized ratio (inr) =\< 1.5 (within 30 days of surgery) * activated partial thromboplastin time (aptt) =\< 40 (within 30 days of surgery) * patients must have no fever or evidence of infection or other coexisting medical condition that would preclude epidural placement exclusion criteria: * evidence of severe uncontrolled systemic disease or other comorbidity that precludes liver surgery * history of chronic narcotic use, defined as 30 days or more of preoperative daily narcotic use, measured from the date of surgery * anaphylaxis to local anesthetics or narcotics * previous or current neurologic disease affecting the lower hemithorax or below * major open abdominal/thoracic surgery in the previous 30 days under general anesthesia * technical contraindications to epidural placement: previous thoracic spinal surgery or local skin or soft tissue infection at proposed site for epidural insertion * use of therapeutic anticoagulation within 5 days of surgery (not including venous thromboembolism prophylaxis) * known bleeding diathesis or coagulopathy * psychiatric (untreated or poorly controlled schizophrenia, major depression, or bipolar disorder), or communication (language) barrier that would preclude accurate assessment of postoperative pain and/or ability to answer questionnaires (need to be able to read, comprehend, and answer questions) * inability to comply with study and/or follow-up procedures * patient refusal to participate in randomization * pregnant women are excluded from this study; women of childbearing potential (defined as those who have not undergone defined as those who have not undergone a hysterectomy or who have not been postmenopausal for at least 12 consecutive months) must agree to practice adequate contraception and to refrain from breast-feeding, as specified in the informed consent * patients with obvious unresectable disease prior to signing informed consent * patients with previous ventral hernia repair, cosmetic abdominoplasty or anterior abdominal wall reconstruction