Surgical Quality Assessment of paravertebral catheter placement in minimally invasive esophagectomy: an exploratory post hoc analysis of the PEPMEN- trial

Background: In the recent PEPMEN trial, paravertebral analgesia (PVA) proved to be a viable alternative to thoracic epidural analgesia in transthoracic minimally invasive esophagectomy (MIE). As part of surgical quality assurance, video recordings of PVA catheter placement were obtained. This post-hoc analysis aimed to evaluate the feasibility and reliability of a structured video-based quality assessment tool and to explore potential associations between visually assessed catheter placement quality and clinical outcomes. Methods: The PEPMEN trial randomized 192 patients undergoing MIE with intrathoracic anastomosis to receive either PVA or epidural analgesia. This analysis included patients in the PVA arm with complete video recordings. Two independent reviewers assessed catheter placement using a four-item tool comprising one global quality score and three technical criteria: subpleural pocket formation, pleural puncture, and catheter tip location. Associations between placement quality and recovery outcomes (Quality of Recovery scores or opioid use) were evaluated in an exploratory manner. Results: Of the 98 patients randomized to PVA, 75 (76.5%) had complete video data. High-quality placement was observed in 77.3% of cases by rater one and 56.0% by rater two, with fair interrater agreement (weighted kappa = 0.24). Within the constraints of limited interrater reliability and sample size, no statistically significant associations were observed between placement quality scores and Quality of Recovery (QoR) and opioid use outcomes. Conclusion: Video-based assessment of paravertebral catheter placement demonstrated limited interrater reliability. No associations were observed between visually assessed placement quality and postoperative recovery outcomes. These findings highlight the importance of refinement and validation of assessment tools before their integration into surgical quality assurance strategies aimed at linking surgical quality to postoperative outcomes.