Paravertebral versus EPidural Analgesia in Minimally Invasive Esophageal ResectioN (PEPMEN): A Randomized Controlled Multicenter Trial

Objective: To compare the quality of recovery in patients receiving epidural or paravertebral analgesia for minimally invasive esophagectomy (MIE). Background: Paravertebral analgesia may be a promising alternative to epidural analgesia, avoiding potential side effects and improving postoperative recovery. Methods: This randomized controlled superiority trial was conducted across 4 Dutch centers with esophageal cancer patients scheduled for transthoracic MIE with intrathoracic anastomosis, randomizing patients to receive either epidural or paravertebral analgesia. The primary outcome was Quality of Recovery (QoR-40) on the third postoperative day (POD). Secondary outcomes included quality of life, postoperative pain, opioid consumption, inotropic/vasopressor medication use, hospital stay, complications, readmission, and mortality. Results: From December 2019 to February 2023, 192 patients were included: 94 received epidural and 98 paravertebral analgesia. QoR-40 score on POD3 was not different between groups (mean difference: 3.7, 95% CI: -2.3 to 9.7; P=0.268). Epidural patients had significantly higher QoR-40 scores on POD1 and 2 (mean difference: 7.7, 95% CI: 2.3-13.1; P=0.018 and mean difference: 7.3, 95% CI: 1.9-12.7; P=0.020) and lower pain scores (median 1 vs 2; P<0.001 and median 1 vs 2; P=0.033). More epidural patients required vasopressor medication on POD1 (38.3% vs 13.3%; P<0.001). Urinary catheters were removed earlier in the paravertebral group (median POD3 vs 4; P<0.001). No significant differences were found in postoperative complications or hospital/intensive care unit stay. Conclusions: This randomized controlled trial did not demonstrate the superiority of paravertebral over epidural analgesia regarding the quality of recovery on POD3 after MIE. Both techniques are effective and can be offered in clinical practice.