Esophagectomy is possible with TAP! Avoid the epidural: A retrospective cohort review

Abstract

Abstract Background: Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to the surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, there can be complications related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominus plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA. Methods: This is a retrospective study of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block in the absence of TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, time to enteral diet, reported postoperative pain scores, development of anastomotic leak, and 30-day readmission. Results: The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. 35 (83.3%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only six patients (14%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain. Conclusion: The results of this study demonstrate TAP blocks do provide comparable rates of successful immediate extubation and reintubation to TEA with fewer hypotensive complications after trans-hiatal esophagectomy. This was shown despite the elevated comorbidity burden of this study’s population. Additionally, TAP blocks maintained similar reported pain control scores to TEA literature.Overall, this study supports the use of TAP blocks as the primary analgesia in patients undergoing trans-hiatal esophagectomy over TEA. Trial Registration: This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R