Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial)

Abstract

Background: Thoracic epidural analgesia is the standard postoperative pain management strategy in esophageal cancer surgery. However, paravertebral block analgesia may achieve comparable pain control while inducing less side effects, which may be beneficial for postoperative recovery. This study primarily aims to compare the postoperative quality of recovery between paravertebral catheter versus thoracic epidural analgesia in patients undergoing minimally invasive esophagectomy. Methods: This study represents a randomized controlled superiority trial. A total of 192 patients will be randomized in 4 Dutch high-volume centers for esophageal cancer surgery. Patients are eligible for inclusion if they are at least 18 years old, able to provide written informed consent and complete questionnaires in Dutch, scheduled to undergo minimally invasive esophagectomy with two-field lymphadenectomy and an intrathoracic anastomosis, and have no contra-indications to either epidural or paravertebral analgesia. The primary outcome is the quality of postoperative recovery, as measured by the Quality of Recovery-40 (QoR-40) questionnaire on the morning of postoperative day 3. Secondary outcomes include the QoR-40 questionnaire score Area Under the Curve on postoperative days 1-3, the integrated pain and systemic opioid score and patient satisfaction and pain experience according to the International Pain Outcomes (IPO) questionnaire, and cost-effectiveness. Furthermore, the groups will be compared regarding the need for additional rescue medication on postoperative days 0-3, technical failure of the pain treatment, duration of anesthesia, duration of surgery, total postoperative fluid administration day 0-3, postoperative vasopressor and inotrope use, length of urinary catheter use, length of hospital stay, postoperative complications, chronic pain at six months after surgery, and other adverse effects. Discussion: In this study, it is hypothesized that paravertebral analgesia achieves comparable pain control while causing less side-effects such as hypotension when compared to epidural analgesia, leading to shorter postoperative length of stay on a monitored ward and superior quality of recovery. If this hypothesis is confirmed, the results of this study can be used to update the relevant guidelines on postoperative pain management for patients undergoing minimally invasive esophagectomy.

Effect of Single-Injection Thoracic Paravertebral Block via the Intrathoracic Approach for Analgesia After Single-Port Video-Assisted Thoracoscopic Lung Wedge Resection: A Randomized Controlled Trial

“…However, the requirements for ultrasound imaging and block technology are high, the operation space is limited and the difficulty is greater, the success rate is low. There is a possibility of puncturing the pleura and damaging the intercostal nerve or sympathetic chain [8,21,23,24]. Compared with TPB, erector spinae plane block has a higher success rate, but requires higher ultrasound imaging and block technique [19].…”

Feasibility and effectiveness of multi-injection thoracic paravertebral block via the intrathoracic approach for analgesia after thoracoscopic-laparoscopic esophagectomy

“…The second method is to place the catheter in the paravertebral space through percutaneous puncture outside the pleura under thoracoscopic direct vision, this can achieve a similar continuous block as the catheter placed under ultrasound guidance. TPB can effectively reduce both the postoperative pain and consumption of opioids after thoracic surgery [ 7 , 24 , 26 , 27 ]. Both TPBs require at least three to five minutes during the procedure, possibly longer if the action is not smooth.…”

Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit

“…The hypotensive effect of epidural anesthesia might require inotropic hemodynamic support at an ICU level of care. Paravertebral analgesia has enjoyed increasing interest in recent years since it may reduce the incidence of hypotensive events and therefore instigate shorter ICU stay [24,25]. Hospital logistics might also play a crucial role in the hospital variation found in the current study.…”