Can video-guided paravertebral block replace thoracic epidural analgesia in minimally invasive esophagectomy?

A patient’s postoperative experience is shaped by various factors, including comfort, physical mobility, independence, psychological well-being, pain management and freedom from complications (1). Historically, thoracic epidural analgesia (TEA) has been the gold standard for postoperative analgesia in traditional open thoracic surgery (2). Despite its efficacy in pain relief, TEA use is associated with undesirable effects such as sympathectomy-induced hypotension, urinary retention, technical challenges in catheter placement, catheter displacement and rare but severe neuraxial complications (3).

The development of minimally invasive surgical techniques and enhanced recovery after surgery (ERAS) protocols has necessitated a re-evaluation of TEA in the context of esophagectomy. In minimally invasive esophagectomy (MIE), small incisions reduce localized pain and enhance patient recovery (4). However, the extent of overall tissue trauma in a major surgery like esophagectomy should not be underestimated. This raises an important question: can an alternative to TEA offer comparable pain control while avoiding its drawbacks and promoting optimal patient recovery?

Paravertebral block (PVB) has been well-described as an equivalent analgesic technique to TEA in thoracotomy and video-assisted thoracoscopic surgery (VATS) but evidence for its efficacy in MIE remains limited (5,6). A previous meta-analysis has called for a direct comparison between epidural and paravertebral analgesia in the context of MIE (7).

The study by Feenstra et al. addressed this gap by comparing the quality of recovery with continuous PVB and continuous TEA in an unblinded, randomized, prospective superiority trial involving patients undergoing MIE (8). In this trial, surgeons placed paravertebral catheters at the beginning of the thoracic phase of the operation using thoracoscopic guidance, whereas epidural catheters were placed by the anesthesiologist prior to induction of anesthesia. A novel feature of the PVB approach was video recording of the procedure for subsequent quality assessment, which was rated as “good” in the overwhelming majority. Video guidance helped to overcome some of the challenges of a landmark or an ultrasound guided procedure (9).

The trial included 192 patients (94 in TEA, 98 in PVB) in the intention to treat analysis and 179 (86 in TEA, 93 in PVB) in the per protocol analysis. This gave the trial adequate statistical power to detect a minimally clinically important difference in the Quality of Recovery 40 (QoR40) score of 6.3 points. In six patients, epidural catheter placement was unsuccessful, five of which went on to have PVB catheters placed intraoperatively. Baseline characteristics were well matched between groups.

The primary outcome was the QoR40 score on post-operative day (POD) 3. The mean QoR40 score was 168.8 in the TEA group and 165.1 in the PVB group—a non-significant difference. However, TEA showed significantly better QoR40 scores on POD1 and POD2 (mean differences of 7.7 and 7.3 respectively). TEA provided better pain control throughout, though the differences were no longer significant by POD3. Abdominal pain was notably greater in the PVB group. Similar rates of catheter dislodgement or removal because of ineffective analgesia were observed in each group. More patients in the TEA group required vasopressor support on POD1 (38.3% versus 13.3%) but fluid balance was similar in both groups. Complications did not differ between groups, although there were non-significant trends towards more anastomotic leaks in the TEA group (13.8 % versus 6.1%) and fewer pneumonias (11.7% versus 18.4%).

This study did not demonstrate the superiority of PVB over TEA in MIE in terms of quality of recovery. To conclude that quality of recovery on POD3 was similar in both groups would have required a non-inferiority trial design. Nevertheless, the authors argue that their findings support the safety of PVB as a viable alternative to TEA, though the study was underpowered to assess rare outcomes.

What insights can we draw from this trial? While TEA offered statistically better analgesia the clinical relevance of this difference is debatable (5). Prior research by Wu et al. demonstrated comparable analgesic outcomes between PVB and TEA for VATS lung resection (6). Esophagectomy involves greater tissue trauma than lung resection due to its combined thoracic and abdominal components. Extensive pleural dissection may also compromise the continuity of the paravertebral space affecting the distribution of local anesthetic (10). Spread of local anesthetic within the paravertebral space might have been enhanced by programmed intermittent bolus delivery rather than continuous infusion (11). The addition of subcostal transversus abdominis plane (TAP) blocks to PVB could be used to address the difference seen in abdominal pain (12).

An important limitation of TEA is its role in the genesis of perioperative hypotension and the need for vasopressor support (13). There is an association between hypotensive episodes and the incidence of anastomotic leak after esophagectomy, but a causal relationship remains speculative (14,15). The authors of this study report that three epidural catheters had to be removed in the postoperative period because of hypotension although this finding is of uncertain value as no blood pressure data were provided. The increased incidence of anastomotic leak and need for norepinephrine vasopressor support in the TEA group is potentially important, but further investigations are needed to conclude on this issue.

The optimal analgesic regimen for MIE remains to be determined. Feenstra et al. should be commended for undertaking this large, randomized trial to address this important clinical question. Video-guided PVB is a feasible technique, with potentially fewer adverse effects than TEA. As esophageal surgery evolves, including the use of robotic approaches, PVB may become an integral component of an individualized multimodal analgesic strategy. It is a technique that should continue to be studied and refined to further enhance recovery and patient outcomes in MIE.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, AME Surgical Journal. The article has undergone external peer review.

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-24-52/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-24-52/coif). The authors have no conflicts of interest to declare.

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