Epidural anesthesia in esophagectomy: a systematic review and meta-analysis

Esophageal resection, which is the primary treatment of esophageal cancer, is associated with a high risk of morbidity and often leads to significant postoperative pain. This study aimed to evaluate the effect of thoracic epidural analgesia (TEA) on pain management and postoperative outcomes in esophageal cancer surgery.

A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (International Prospective Register of Systematic Reviews identification number: CRD42024501967), encompassing studies from the Embase, PubMed, Cochrane, and LILACS databases. Controlled trials and cohort studies comparing TEA with alternative anesthesia strategies, such as patient-controlled analgesia, were considered for inclusion. The outcomes were pain visual score, use of pain rescue medications, hospital stay, intensive care unit (ICU) stay, blood loss, extubation time, operation time, postoperative complications, severe complications, catheter-related complications, opioid-related sedation, mortality, anastomotic leak, pulmonary complications, reintubation, readmission, and vasoactive drug use.

A total of 15 studies with 16,146 patients were selected, consisting of 7 controlled trials, 7 retrospective cohorts, and 1 prospective cohort. TEA was associated with significant reductions in pain scores (mean difference [MD]: -0.83 [95% CI, -1.18 to -0.49]), length of stay (MD, -2.3 days [95% CI, -2.78 to -1.73]), extubation time (MD, -0.13 h [95% CI, -0.17 to -0.08]), severe postoperative complications (risk difference [RD], -0.05 patients [95% CI, -0.08 to -0.03]), anastomotic leakage (RD, -0.03 [95% CI, -0.04 to -0.01]), and pulmonary complications (RD, -0.10 patients [95% CI, -0.19 to -0.02]). The operation times were slightly longer in the TEA group (MD, 7.77 min [95% CI, 0.69-14.85]). TEA was associated with a higher risk of catheter-related complications (RD, 0.09 [95% CI, 0.01-0.17]) and higher use of vasoactive drugs (RD, 0.02 [95% CI, 0.00-0.04]). No significant differences were observed for ICU stay, blood loss, mortality, reintubation, readmission, opioid sedation, or use of rescue medication.

Our findings highlight TEA as an effective strategy for enhancing postoperative recovery in patients with esophageal cancer. TEA not only reduces pain scores but also improves postoperative surgical outcomes, including fewer complications, shorter extubation times, and reduced hospital stays.