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How to transit an epidural Does epidural analgesia (EDA) still have a role in postoperative pain relief after abdominal surgery?Or have modern surgical principles and the introduction of multimodal pain relief made EDA redundant? In an editorial in BJS, Lobo and Joshi ask this inevitable question1 For many years, EDA was the cornerstone of pain relief after abdominal surgery, and it still plays an important role in many major procedures. Unfortunately, there is a high failure rate of 15–25% with EDA, even in skilled hands and with good routines. Many patients will also require vasoactive medication and fluid overload may occur in the perioperative course due to EDA-related hypotension. Urinary retention that necessitates a bladder catheter as long as the EDA is active is common. In some patients with platelet dysfunction and coagulopathy or those on anticoagulation, epidural anesthesia may be contraindicated due to the increased risk of epidural hematoma. In addition, postoperative anticoagulation in therapeutic doses may be in conflict with removal of the EDA catheter.At our department, we have conducted a randomized controlled trial demonstrating that a new treatment with multimodal pain analgesia was non-inferior compared to EDA with regard to overall postoperative pain during the first 6 PODs2 in open liver surgery.3 In the intervention (non-epidural) group, patients received a non-steroidal anti-inflammatory drug (NSAIDs)(Ketorolac in our study) on postoperative days (POD) 0–2, and patient-controlled analgesia (PCA) with ketobemidone (a strong opioid). Both groups received a single dose of steroids at the start of anesthesia, and paracetamol throughout the course. In the intervention (non-epidural) group the surgical wound was infiltrated with local anesthesia. The main finding of the study was that multimodal analgesia provided the same good pain relief on POD 0–6 as EDA, (mean pain score, NRS 1.7 vs 1.6), providing non-inferiority. Not unexpectedly, EDA gave slightly better pain relief on POD 0 and 1, but thereafter multimodal pain relief was better than EDA. Another important finding was that the PCA pumps were much easier to discontinue than EDA, and the patients in the intervention group was discharged from hospital one day earlier than the EDA group, 3 vs 4 days.The tapering of a well-functioning epidural can often be challenging following procedures enhanced recovery after surgery (ERAS) protocol enables short hospital stays. The patients with EDA have then been adapted to little or no pain, and if the tapering is too rapid, the patient will experience breakthrough pain, which can often be a reason for delayed discharge. In a retrospective study in hepato-pancreatic surgery using EDA, rebound pain occurred in nearly 30% in the patients after EDA removal, resulting in poorly controlled pain relief.4 Rebound pain is defined as a sudden and intense increase in pain after removal of a regional block or catheter. There is no easy way to avoid this phenomenon. In our unit we introduce slow-acting oxycodone on the evening at POD 2 (institutional epidural and ERAS guidelines) to facilitate the reduction of EDA, and reduce EDA infusion rate with 30% every three hours. If the patients experiences good pain relief with oral medication alone, we will try to remove EDA in the morning at POD 3 or 4. When EDA is not possible to remove because of inadequate pain control, we will consider oral medication with NSAIDs and an alpha-2 adrenergic agonist like clonidine, together with opioids and paracetamol. Some patients may need further assessment in collaboration with the acute pain team.Early epidural removal has been reported to be successful in orthopedic surgery.5 In this study there was a significant reduction in opioid use and hospital stay in patients undergoing periacetabular osteotomy who had early catheter removal on POD1 compared to catheters removed on POD2. Patients who had their epidural catheter removed on POD1 reported significantly lower mean pain on their date of epidural removal compared with patients with epidural removal on POD2. All patients in this study received standard multimodal analgesia including oral and iv opioids, NSAIDs, aspirin and paracetamol. There were no differences in the rates of complication including readmission.Several well-conducted RCTs have shown the similar findings as our study, and there are many alternative methods for pain relief after abdominal surgery, even after complex open surgical procedures.6 The introduction of opioid-sparing regimens with intravenous infusion of lidocaine and ketamine has received increased interest. Intrathecal morphine is also a good alternative that is easy to perform and with high rates of adequate postoperative pain relief. Furthermore, ultrasound-guided truncal blocks and abdominal wound catheter with local anesthetics have shown effective pain relief after abdominal surgery in many studies. We must not forget the surgeons either, many blocks performed by the surgeon are suitable for a majority of surgical procedures.7 At our department, we have a close and good collaboration with both urologists, and gastroenterology and transplant surgeons for the establishment of abdominal wall blocks. Together with a single dose of steroids and NSAIDs these alternative methods will give an adequate pain relief after abdominal surgery in the majority of patients.For the future we may need a more tailored approach to pain management in selected patients undergoing complex surgery. In our opinion we will need both EDA and multimodal pain management strategies. In patients with chronic pain conditions, when NSAIDs are not recommended or in patients with an expected hospital stay of more than 5 days, EDA will often be our first option. With low risk profile (i.e. no significant renal or cardiopulmonary insufficiency, not advanced age) and minimally invasive procedures we will recommend multimodal analgesia or ultrasound guided truncal blocks were appropriate.Due to the rapid development of new surgical techniques in abdominal surgery, studies to investigate the best way to provide postoperative pain relief to this patient group are warranted.References Lobo DN, Joshi GP. Pain management after abdominal surgery: requiem for epidural analgesia? Br J Surg. 2024;111(12).Hausken J, Fretland Å, Edwin B, et al. Intravenous patient-controlled analgesia versus thoracic epidural analgesia after open liver surgery: a prospective, randomized, controlled, noninferiority trial. Ann Surg. 2019;270(2):193–199.Fretland Å, Dagenborg VJ, Bjørnelv GMW, et al. Laparoscopic versus open resection for colorectal liver metastases: the OSLO-COMET randomized controlled trial. Ann Surg. 2018;267(2):199–207.Kwon HJ, Kim YJ, Lee D, et al. Factors associated with rebound pain after patient-controlled epidural analgesia in patients undergoing major abdominal surgery: a retrospective study. Clin J Pain. 2022;38(10):632–639.Cunningham DJ, Kovacs D, Norcross W, et al. The impact of early epidural discontinuation on pain, opioid usage, and length of stay after periacetabular osteotomy. J Bone Joint Surg Am. 2020;102(Suppl 2):59–65.Pirie K, Traer E, Finniss D, et al. Current approaches to acute postoperative pain management after major abdominal surgery: a narrative review and future directions. Br J Anaesth. 2022;129(3):378–393.Rawal N. Epidural analgesia for postoperative pain: improving outcomes or adding risks? Best Pract Res Clin Anaesthesiol. 2021;35 (1):53–65.