Intertransverse Process Block With Catheter Placement for Postoperative Pain Management in a Patient With Alcoholic Liver Disease and Portal Hypertension: A Case Report.

Abstract

Epidural analgesia is typically avoided in patients with portal hypertension due to multiple risk factors: engorgement of epidural venous plexuses, platelet dysfunction despite normal counts, and potential postoperative coagulopathy following liver surgery. These risks persist even when preoperative coagulation parameters appear normal. While peripheral nerve blocks are increasingly utilized for minimally invasive laparoscopic procedures, intertransverse process block (ITPB) with catheter placement offers a high-quality analgesic strategy that supports early ambulation and postoperative recovery with a significantly reduced risk profile in such patients. A 76-year-old male patient with alcoholic liver cirrhosis (Child-Pugh class A) and a history of esophageal variceal bleeding underwent laparoscopic partial hepatectomy of segment 3 for suspected hepatocellular carcinoma. Despite normal coagulation parameters (prothrombin time-international normalized ratio 1.1 and activated partial thromboplastin time 33 seconds), epidural analgesia was contraindicated due to portal hypertension with multiple vascular anomalies. Bilateral ultrasound-guided ITPB was performed at the Th8-9 level with catheter placement in the intertransverse tissue complex. Analgesia was maintained with intermittent boluses of 0.25% levobupivacaine (10 mL bilaterally, twice daily) for three postoperative days, supplemented with intravenous patient-controlled analgesia (IV-PCA) fentanyl (baseline infusion 10 μg/hour, bolus dose 10 μg, lockout time 10 minutes). The patient reported minimal pain scores (numerical rating scale 0-2 at rest, 2-3 with movement), achieved early mobilization, and did not require any PCA boluses throughout recovery. Cold testing confirmed adequate sensory blockade from Th8 to Th11 on each postoperative day until catheter removal. ITPB with catheter placement provided safe and effective analgesia in a patient with portal hypertension, enabling early mobilization and rehabilitation without risking complications associated with epidural techniques. This approach represents a viable alternative to epidural analgesia in high-risk patients with compromised liver function and vascular abnormalities.