Comparison of thoracic epidural anesthesia with an erector spinae plane infusion for post-esophagectomy analgesia: a pragmatic retrospective cohort study.

Background: Effective pain management following esophagectomy facilitates recovery and may reduce the conversion from acute to chronic pain. Thoracic epidural analgesia (TEA) has been the standard of care for pain management following esophagectomy; however, serious adverse effects and complications of TEA use have been reported. The erector spinae plane (ESP) block has been reported as an alternative analgesia technique, yet no studies have compared TEA with ESP. To address this knowledge gap, we performed a quasi-experimental design study of retrospective data from a 9-year period to compare TEA and ESP analgesia. Methods: With Institutional Review Board (IRB) approval, medical records of patients undergoing an esophagectomy procedure [2016-2023] at a single institution (Rush University Medical Center) were studied. Clinical characteristics, co-morbidities, operative data, regional analgesia (ESP vs. TEA), postoperative pain and analgesic use were collected. The primary outcome was the area under the pain-by-time curve for 72 h (AUC0-72h). Secondary outcomes were average pain, and opioid use in morphine milligram equivalents (MME). Outcomes were compared between propensity score weighted groups using a generalized linear model adjusted for year of the procedure. Results: Ninety-nine esophagectomies were identified and 79 included in the analysis. Seventy were performed using the Ivor-Lewis (2-hole) and 9 using the McKeown (3-hole) approach. Forty-four patients received TEA and 35 ESP analgesia. The ESP minus TEA difference in the AUC0-72h was -61 score*h [95% confidence interval (CI): -128 to 6, P=0.07]. The mean pain score over 72 h was 2.9 (95% CI: 2.2 to 3.6) in the TEA and 3.9 (95% CI: 3.4 to 4.6) in the ESP group, difference -1.0 (95% CI: -1.9 to -0.2, P=0.02). Total weighted and adjusted intravenous (iv) MME over 72 h were 99 MME (95% CI: 73 to 125) in the TEA and 134 MME (95% CI: 106 to 161) in the ESP group, difference -34 MME (95% CI: -74 to 6, P=0.09). Catheter related complications occurred in 2 of 35 (6%) ESP and in 4 of 44 (10%) TEA patients (P=0.89). Pain increased on the day after surgery and decreased over the next 2 days in both groups. Opioid use was greatest on the day of surgery, decreased significantly on days 1 to 3 postoperatively in the TEA group, but remained unchanged from day of surgery to postoperative day 2 in the ESP group. Conclusions: Our study demonstrated no significant differences in AUC0-72h or total opioid consumption over 72 h between TEA and ESP analgesia following esophagectomy. The average reported pain over 72 h was significantly greater in the ESP group and exceeded the clinical important threshold of 0.5, and opioid analgesia consumption exceeded the minimally clinically important threshold of 10 MME/day. ESP analgesia may represent an alternative to TEA and reduce catheter-related side effects; however, it likely offers somewhat reduced analgesia requiring greater opioid supplementation.