Liposomal bupivacaine in thoracic surgery: a comprehensive review of current evidence and clinical implications

Liposomal bupivacaine (LB) is a prolonged-release formulation designed to provide postoperative analgesia for up to 72-96 h after a single injection. This comprehensive review evaluates the current evidence on LB in thoracic surgery, focusing on acute pain control, opioid consumption, hospital length of stay (LOS), functional recovery, comparative effectiveness across regional techniques, integration into Enhanced Recovery After Surgery (ERAS) protocols, chronic postsurgical pain (CPSP) reduction, and safety/cost considerations. The core critical finding of this review is that although meta-analyses show statistically significant reductions in pain scores and opioid consumption with LB, the clinical significance of these reductions is questionable-for example, the opioid-sparing effect at 24 h (-1.83 MME) is far below the threshold generally considered clinically meaningful (10-15 MME). Results vary by block type; benefits are more consistent with serratus anterior, erector spinae, and paravertebral blocks, while intercostal nerve block data are mixed. LB appears most effective when incorporated into ERAS protocols, although the independent contribution of LB within these multimodal pathways remains difficult to isolate. Emerging evidence suggests LB may reduce CPSP incidence by 30-58%, but these findings are preliminary and require confirmation in larger studies with longer follow-up. Safety profiles are favorable, with peak plasma concentrations well below toxicity thresholds. Methodological limitations of the existing evidence include small sample sizes, lack of blinding, and and heterogeneity across studies. Future large-scale RCTs with long-term follow-up are warranted.