Transition From Epidural to Paravertebral Analgesia After Minimally Invasive Ivor Lewis Esophagectomy

Paravertebral analgesia may be a safe and adequate alternative to epidural analgesia during and after minimally invasive Ivor Lewis esophagectomy and may be associated with a lower incidence of post-thoracotomy pain syndrome, side effects, and complications. The aim of this study is to monitor the transition from epidural to paravertebral analgesia after minimally invasive Ivor Lewis esophagectomy and to compare both techniques through the transition period.

In this single-center retrospective study, patients undergoing elective minimally invasive Ivor Lewis esophagectomy between January 2016 and November 2023 were included. All patients with paravertebral analgesia since the introduction of paravertebral analgesia in 2020 were included and case-matched with patients receiving epidural analgesia from the period before. Data were obtained from electronic patient files. The primary endpoint was the amount of additional analgesia medication needed and patient pain scores within 4 days postoperatively. Secondary endpoints were postoperative complications, requirement of vasopressor support, analgesia side effects and complications, and the length of ICU stay.

Baseline characteristics were similar for both analgesia groups. The paravertebral patients noted significant higher NRS scores. However, no difference in requirement of rescue analgesia was observed between the paravertebral and epidural analgesia groups. In addition, more patients in the epidural analgesia group reported insufficiency of analgesia. Patients receiving epidural analgesia had a longer ICU stay, were more likely to develop hypotension, and required significantly more vasopressor. Moreover, when vasopressors were needed, the dosage of vasopressors was higher in this group. More obstipation and hypotension were described in the epidural analgesia group. The epidural analgesia group also showed more pulmonary complications, such as pleural fluid, and mediastinitis. No statistical difference was found in (technical) analgesia complications.

From the onset of the transition from epidural to paravertebral analgesia after minimally invasive Ivor Lewis esophagectomy, paravertebral analgesia is as adequate as epidural analgesia but is superior in respect to vasopressor use and concomitant duration of ICU stay.