LAUSR

Thoracic epidural (TE) analgesia has been the gold standard for pain management post-esophagectomy and is still being widely used. While it offers excellent analgesia, it can negatively impact on recovery due to hypotension. An alternative is multimodal analgesia using intrathecal-diamorphine, paravertebral and rectus sheaths local anaesthetic infusion-catheters (LAC) and intravenous opioids (PCA). The aim of this study was to compare the effectiveness of TE analgesia and multimodal LAC analgesia and the associated incidence of hypotension. Data were collected over a three-year period for patients who underwent trans-thoracic (Ivor Lewis) esophagectomy from a single high volume unit. Multimodal analgesia was integrated into the patient pathway in early 2016 and adopted by all team members. All patients were treated post operatively with a standardised enhanced recovery pathway. Pain scores using a visual analogue scale (VAS) at rest and movement, episodes of hypotension (systolic BP < 90 mmHg) and vasopressor requirements for post-operative days 0 to 4 (POD 0–4) were recorded for both groups. Overall 239 patients were included in this study, 104 patients received TE analgesia and 135 patients received multimodal analgesia. There was no statistically significant difference in the mean VAS pain scores between both cohorts on all post-operative days. (p = 0.06–0.89). In comparison to TE analgesia, the multimodal patient group had significantly fewer episodes of hypotension (multimodal: 21% vs TE: 38%, p = 0.01) and significantly less vasopressor infusion requirements to maintain their blood pressure (multimodal: 30% vs TE: 55%, p = 0.01). Multimodal analgesia using intrathecal diamorphine with combined paravertebral and rectus sheath catheters is not inferior to TE in providing pain control post esophagectomy. In addition there are significantly fewer episodes of hypotension and significantly less need for vasopressor use. This may confer a postoperative advantage permitting better patient mobilisation and recovery in the immediate post operative period.