Rectus sheath catheters versus thoracic epidural analgesia for pain management after open surgery: systematic review and meta-analysis

Thoracic epidural analgesia (TEA) remains the 'gold standard' for postoperative pain management after major open surgery, but is potentially associated with hypotension, urinary retention, and delayed recovery. Rectus sheath catheters (RSCs) offer a simple regional alternative that avoids sympathetic blockade while maintaining somatic analgesia. The aim of this review was to compare analgesic efficacy, complications, recovery, patient satisfaction, and costs between RSCs and TEA in open surgical procedures.

This systematic review was registered with PROSPERO, the international prospective register of systematic reviews (registration number: CRD420251234467). A systematic PubMed search was conducted to identify studies comparing continuous wound infusion via RSCs with TEA in adult patients undergoing open abdominal, pelvic, thoracic, or vascular surgery. RCTs, as well as prospective and retrospective comparative studies, were included. A meta-analysis was performed for randomized trials.

In total, 31 studies (21 prospective and 10 retrospective) involving 2162 patients were included. RSCs and TEA did not differ significantly with respect to postoperative pain (standardized mean difference -0.35 (95% c.i. -2.01 to 1.32)) or opioid consumption (standardized mean difference -0.32 (95% c.i. -1.71 to 1.07)). No differences were observed in recovery of bowel function, urinary retention, time to mobilization, or length of hospital stay. RSCs significantly reduced the risk of hypotension compared with TEA (risk ratio 0.40 (95% c.i. 0.26 to 0.60)) and were associated with lower costs with savings ranging from $500 to $6632 per case. Subgroup analyses suggested less urinary retention and earlier mobilization with RSCs in non-visceral surgery and non-laparotomy incisions.

RSCs provide analgesia comparable to TEA with fewer complications, facilitating earlier recovery and potential cost savings. Considering the growing shift toward fast-track surgery, RSCs represent a pragmatic and resource-efficient alternative for postoperative pain management in open surgical procedures.