Postoperative analgesia after combined thoracoscopic–laparoscopic esophagectomy: a randomized comparison of continuous infusion and intermittent bolus thoracic epidural regimens

PURPOSE: Judicious postoperative pain management after thoracoscopic–laparoscopic esophagectomy (TLE) facilitates enhanced rehabilitation. Thoracic epidural analgesia (TEA) offers many benefits in esophagectomy, while several complications are associated with the delivery mode by continuous epidural infusion. This study compared the efficiency and safety of intermittent epidural bolus to continuous epidural infusion for pain management after TLE. PATIENTS AND METHODS: Sixty patients, aged 18–80 years, with American Society of Anesthesiologists classes I–III and scheduled for TLE with combined general anesthesia and TEA were randomly allocated to two groups. Patients received either a continuous epidural infusion with 0.3% ropivacaine and 1.5 µg/mL fentanyl at 6 mL/h plus a patient-controlled bolus of 3 mL (continuous group) or an intermittent bolus of 6 mL of the same solution on demand with lockout time of 30 minutes (intermittent group). If the patient complained of pain and the visual analog scale score was >4, an intravenous injection of tramadol or dezocine was administered as rescue treatment. The primary outcome variable was the consumption of epidural opioids and local anesthetics for TEA. RESULTS: TEA for pain management following TLE by intermittent epidural bolus was associated with significantly lower consumption of fentanyl and ropivacaine and lower incidences of breakthrough pain and hypotension than continuous epidural infusion. No significant differences were observed between the two groups in terms of pain score at rest or while coughing, patient satisfaction, or incidence of postoperative complications. CONCLUSION: Compared with continuous epidural infusion, TEA by on-demand intermittent bolus greatly reduced the consumption of local anesthetics and opioids with comparable pain relief and little impairment in hemodynamics when used for pain management after TLE.