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EPIDURAL ANESTHESIA IN ESOPHAGECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS
Thiago Oliveira3, Eric T. Nakamura2, Fernanda Hanada Baltazar Harada2, Maria Luiza V. Olivé1, Isabela Martinez3, Arthur Oliveira3, Felipe Antonio B. Maegawa5, Victor H. Shimanoe4, Francisco Tustumi*1
1Sociedade Beneficente Israelita Brasileira Albert Einstein, Sao Paulo, São Paulo, Brazil; 2Universidade de Mogi das Cruzes, Mogi das Cruzes, SP, Brazil; 3Centro Universitario Lusiada, Santos, São Paulo, Brazil; 4Universidade de Sao Paulo, Sao Paulo, Brazil; 5Emory University, Atlanta, GA

Background: Esophageal resection, which is the primary treatment for esophageal cancer, is associated with a high risk of morbidity and often leads to severe postoperative pain. This review evaluates the impact of thoracic epidural analgesia (TEA) on pain management and postoperative outcomes in esophageal cancer surgery. Methods: A systematic review and meta-analysis was conducted following the PRISMA guidelines (PROSPERO: CRD42024501967), encompassing studies from Embase, PubMed, Cochrane, and LILACS databases. Controlled trials and cohort studies comparing TEA to alternative anesthesia strategies, such as patient-controlled analgesia (PCA), were considered for inclusion. The outcomes were pain visual score, use of pain rescue medications, hospital stay, 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 subgroup analysis was performed, including only studies comparing TEA and PCA. Results: Fifteen studies, with 2226 patients, were selected, comprising seven controlled trials, seven retrospective cohorts, and one prospective cohort. TEA was associated with significant reductions in pain scores (MD: -0.83; 95% CI: -1.18 to -0.49), hospital length of stay (MD: -2.3 days; 95% CI: -2.78 to -1.73), extubation time (MD: -0.13 hours; 95% CI: -0.17 to -0.08), severe postoperative complications (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). Operation times were slightly longer in the TEA group (MD: 7.77 minutes; 95% CI: 0.69 to 14.85). No significant differences were observed for ICU stay, blood loss, mortality, reintubation, readmission, opioid sedation, vasoactive drug use, or rescue medication. Compared to PCA, TEA resulted in lower pain scores (MD: -0.93; 95% CI: -1.64 to -0.22) and fewer pulmonary complications (RD: -0.21 patients; 95% CI: -0.34 to -0.07) but was associated with an increase in catheter-related complications (RD: 0.10 patients; 95% CI: 0.03 to 0.18). No significant differences were noted in hospital stay, ICU stay, blood loss, extubation time, postoperative mortality, anastomotic leakage, readmission, opioid sedation, or rescue medication use. Conclusions: The findings highlight TEA as an effective strategy to enhance postoperative recovery in esophageal cancer patients. TEA not only reduces pain scores but also improves postoperative surgical outcomes, including fewer complications, shorter extubation times, and reduced hospital stays.


Baseline characteristics of the included studies. Fifteen studies, with 2226 patients, were selected, comprising seven controlled trials, seven retrospective cohorts, and one prospective cohort.

Comparison of thoracic epidural analgesia (TEA) with other analgesic strategies for pain management and postoperative outcomes in esophageal cancer surgery. Results are reported as mean or risk differences, along with a 95% confidence interval (lower and upper limits) and statistical heterogeneity (I2).
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