Analgesic efficacy of surgeon placed paravertebral catheters compared with thoracic epidural analgesia after Ivor Lewis esophagectomy: a retrospective non-inferiority study

Abstract

Background: The Ivor Lewis esophagectomy is an operation that involves a laparotomy and a right thoracotomy, both of which are associated with severe postoperative pain and subsequent impairment of respiratory function. Currently, the accepted "gold standard" for postoperative analgesia for laparotomies and thoracotomies is the thoracic epidural. A systematic review has shown paravertebral blocks to be equivalent to epidural analgesia for post-thoracotomy pain control and have decreased incidence of nausea and vomiting, hypotension and respiratory depression. To our knowledge, the use of the paravertebral catheter (PVC) in open Ivor Lewis esophagectomy has not been formally studied. The primary outcome is the area under the curve (AUC) pain scores in the first 48 hours after surgery.

Methods: We performed a retrospective chart review of the open Ivor Lewis esophagectomy patients at our local institution, with local research ethics board (REB) approval.

Results: A total of 92 patients were included in this study: 43 patients had a PVC and 49 had a thoracic epidural for postoperative pan control. Overall, the PVC group was non-inferior and statistically equivalent to the epidural group. Time to ambulation in the PVC group was non-inferior compared to epidurals. The PVC group was superior when comparing total opioid consumption.

Conclusions: Our retrospective study continues to challenge the role of epidurals as the gold standard of pain control post thoracotomy and laparotomy. Further prospective studies with a larger population are needed to better compare the two modalities.

Keywords: Esophagectomy; pain management; paravertebral; thoracotomy.

Video 1

Step by step instructions for inserting a paravertebral catheter intraoperatively for postoperative pain control.

Figure 1

Inclusion and exclusion flow diagram.

Figure 2

Inferiority and equivalence testing of primary and secondary outcomes. The dot indicates the mean difference, the thicker error bars around the dot represent the 90% CI and the thinner bars indicate the 95% CI. The dotted lines indicate the non-inferiority margins. Mean difference is calculated by PVC − epidural. PVC superior: if the 95% CI for the mean difference does not include the lower bounds of the equivalency margin, and the CI contains only negative numbers. PVC inferior: if the 95% CI for the mean difference does not include the upper bounds of the noninferiority margin, and the CI contains only positive numbers. Equivalence: if the 90% CI does not overlap either of the non-inferiority regions. Non-inferiority: if the 90% CI does not include the upper bounds of the non-inferiority margin. AUC, area under the curve; PVC, paravertebral catheter; OME, oral morphine equivalent; CI, confidence interval.