Multimodal analgesia combined with epidural anesthesia and intravenous administration of acetaminophen in perioperative management of esophagectomy using modified ERAS protocol

Introduction: In perioperative management of esophagectomy, we have performed modified ERAS protocol including preoperative oral rehydration, early enteral nutrition, early mobilization, intestinal peristalsis promotion, pain control, and so on. We think these elements are related closely and useful in reducing complication and early recovery after surgery in case of high invasive surgery such as esophagectomy with 3 field lymph node dissection. And we think pain control is particularly close relationship with early mobilization, so multimodal analgesia is very important for postoperative pain control. Methods:We evaluated whether it is possible to reduce postoperative breakthrough pain by using postoperative pain control combined with acetaminophen IV. 135 patients were treated by esophagectomy with 3-field LN dissection from January 2013 to October 2015. Before May 2014, 49 patients were treated without acetaminophen IV protocol (Group A), and after May 2014, 81 patients were treated with acetaminophen IV protocol (Group B). How to use of acetaminophen was 1000mg DIV QID between day3 to day7 in Group B.We compared the number of analgesic drug for breakthrough pain until postoperative day 7, and compared the ratio of liver dysfunction in both groups. Additionally in Group B, we evaluate the number of analgesic drug use depending on epidural anesthesia with 10mg morphine (Group C) or not (Group D). Results: The number of analgesic drug use due to breakthrough pain (Group A/Group B) was day3: 1.08/0.50, day4: 1.53/0.87, day5: 1.69/0.56, day6: 1.14/0.48, day7: 0.79/0.39, and were reduced significantly in Group B (p < 0.05). On the other hand, it was significantly reduced only day2 between group C and D. And liver damage as a side effect by acetaminophen IV, the rise of ALT (Group A/Group B) were seen 32.7%/66.7% in day6, and seen 20.4%/62.7% in day 8, and it was significantly higher in Group B at day6 and day8 (p < 0.01), but was no significant difference in day 30 between both groups. Conclusion: In perioperative management of esophagectomy, pain control combined with acetaminophen IV was useful as multimodal analgesia, especially either with or without epidural anesthesia. Also was ALT rise is seen by liver damage, but it was the minor change in the acceptable range for natural healing.