الفهرس 
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Abstract
Background: Pain management after liver resection has been controversial. The coagulopathy following the surgery is of concern because of the associated risk of epidural hematoma formation particularly in cirrhotic patients undergoing the procedure for a solitary liver tumor excision. Aim: To compare the analgesic efficacy and side effects of patient controlled epidural analgesia (PCEA) versus patient controlled analgesia with intravenous fentanyl (IVPCA). To monitor associated changes in coagulation. Patients and Methods: After ethics committee approval and informed consent, thirty four patients with Child A scheduled for liver resection surgery were studied prospectively and randomised into two equal groups. A group managed with PCEA using a mixture of bupivicaine 0.125% + 2 μgm / ml of fentanyl versus a group with IVPCA using intravenous fentanyl. Prothrombin, partial thromboplastin time, fibrinogen fibrinogen degradation products (FDP) were used to monitor coagulation .Results: PCEA and PCA were found to be similar and effective in pain control at rest during the first three days postoperatively, Mean intensity of pain on a numerical analogue scale (0-10) at rest on day 1 was 5/10, day 2 was 3/10, and day 3was 2/10, but on cough both groups suffered out breaks of pain on first day that needed intravenous meperidine. On day 2 and 3 PCEA group suffered less pain during cough and was more effective. Postoperative sedation score showed significant difference between the PCEA group 2.9 (1.14) and the IVPCA group 3.6(0.51) during the first day. (P <0.05), followed by a significant mean decrease in score by 2nd and 3rd days post operatively in the IVPCA group. Four out of 17 cases in the epidural group complained of bilateral lower limb numbness during the first postoperative day in the PCEA group, due to the established epidural block, but only one patient developed moderate motor block and in this sole case the epidural infusion was stopped with close follow up of the motor status. The mean time for the epidural catheter stay was 5.88±1.27 days before removal, two cases demanded the infusion of fresh frozen plasma units before removal inorder to normalize the abnormally prolonged prothrombin time and high INR Patients in the PCEA group were less sedated and had fewer incidences of side effects as nausea/vomiting. No significant difference as regard the satisfaction assessment of both groups was reported. Conclusion: Intravenous patient controlled with fentanyl was used with no reported side effects in CHILD A cirrhotic patients. Epidural analgesia was delivered safely with no incidence of epidural haematoma, but in view of the associated coagulation changes in conventional tests, it seems more advicable to recommend the intravenous PCA opiods for cirrhotics and a multimodal approach is recommended as no sole technique was enough to control out breaks of pain for such a surgical procedure. Each patient should be informed and consented before surgery about pros and cons of the two techniques and risks weighed against benefits.