Optimal Perioperative Pain Management in Esophageal Surgery: An Evaluation of Paravertebral Analgesia

Abstract

Background: For esophagectomy, thoracic epidural analgesia (TEA) is the standard of care for perioperative pain management. Although effective, TEA is associated with moderate to serious adverse events such as hypotension and neurologic complications. Paravertebral analgesia (PVA) may be a safe alternative. The authors hypothesized that TEA and PVA are similar in efficacy for pain treatment in thoracolaparoscopic Ivor Lewis esophagectomy.

Methods: This retrospective cohort study compared TEA with PVA in two consecutive series of 25 thoracolaparoscopic Ivor Lewis esophagectomies. In this study, TEA consisted of continuous epidural bupivacaine and sufentanil infusion with a patient-controlled bolus function. In PVA, the catheter was inserted by the surgeon under thoracoscopic vision during surgery. Administration of PVA consisted of continuous paravertebral bupivacaine infusion after a bolus combined with patient-controlled analgesia using intravenous morphine. The primary outcome was the median highest recorded Numeric Pain Rating Scale (NRS) during the 3 days after surgery. The secondary outcomes were vasopressor consumption, fluid administration, and length of hospital stay.

Results: In both groups, the median highest recorded NRS was 4 or lower during the first three postoperative days. The patients with PVA had a higher overall NRS (mean difference, 0.75; 95% confidence interval 0.49-1.44). No differences were observed in any of the other secondary outcomes.

Conclusion: For the patients undergoing thoracolaparoscopic Ivor Lewis esophagectomy, TEA was superior to PVA, as measured by NRS during the first three postoperative days. However, both modes provided adequate analgesia, with a median highest recorded NRS of 4 or lower. These results could form the basis for a randomized controlled trial.

Fig. 1

The paravertebral space (thoracal paravertebral block for breast surgery; Beyaz et al. Dicle Med J. 2012)

Fig. 2

Flowchart of patient inclusion.

Fig. 3

Median NRS with epidural or paravertebral analgesia. The y-axis shows the NRS, and the x-axis shows the time expressed in days and shifts (e.g., the first shift was the evening shift immediately after surgery). The p values are corrected for multiple testing with the de Benjamini–Hochberg method