Epidural Analgesia Versus Systemic Opioids for Postoperative Pain Management After VATS: A Systematic Review and...

Firm consensus on the best perioperative pain management after Video-Assisted Thoracic Surgery (VATS) is lacking. Recommendations often assess different loco-regional techniques as part of a multimodal approach, but few discuss omitting regional analgesia altogether, eliminating any risk of procedural complications. A reasonable prerequisite for this approach would be that the alternative provides comparable pain relief. To compare the efficacy of systemic opioids and epidural analgesia for postoperative pain management, we conducted a systematic review and meta-analysis of current studies.

We did a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies on VATS with the primary objective of examining postoperative pain at rest and during activity at POD1, POD2, and POD3. The secondary objectives were to evaluate the efficacy of the treatments, examining the need for postoperative "rescue" opioid, the hospital length of stay, and side effects. We did literature searches of Medline, Embase, and the Cochrane Library from inception to 07 April 2025. Additionally, we searched ClinicalTrials.gov, the EU Clinical Trials Register, the WHO International Clinical Trials Registry Platform, Scopus, and Google Scholar. We included adult patients undergoing VATS receiving either epidural analgesia or systemic opioids for postoperative pain management.

We included four randomized controlled trials (RCTs) and four observational studies encompassing 946 patients. The primary meta-analysis of the RCTs found that epidural analgesia reduced pain compared with systemic opioids by a pooled mean difference of 0.8 NRS/VAS points (95% CI 0.2-1.3) at rest and 1.1 points (0.7-1.5) during activity over POD 1 to 3. Heterogeneity was substantial (I² 99% and 98%, respectively) and was largely explained by the presence of baseline multimodal analgesia on POD 2. Rescue-opioid use was lower with epidurals in three of four trials, with no consistent differences in length of stay or adverse effects. Evidence certainty was moderate. The observed difference is below or at the lower bound of the minimal clinically important difference of 1-2 NRS/VAS points.

Epidural analgesia offers a small but possibly subclinical reduction in acute postoperative pain after VATS compared with systemic opioids, particularly when combined with baseline multimodal analgesia. High heterogeneity and moderate certainty underscore the need for adequately powered trials.

CRD42024598757.