Long-Acting Local Anesthetics for Analgesia Following Thoracic Surgery

Surgery remains the cornerstone therapy for early-stage lung and esophageal cancers. It is expected that the number of thoracic procedures for lung and esophageal disease will increase in the future (Siegel et al. CA Cancer J Clin 62(4):220-241, 2012). Optimal pain management can be very challenging after thoracic surgery for multiple reasons. Not only is inadequate pain control significant for humanitarian reasons, it is also linked to increased pulmonary and extrapulmonary complications (Richardson et al. J Cardiovasc Surg 40:445-456, 1999). The risks of pulmonary complications can be mitigated by appropriate pain management (Ballantyne, Anesth Analg 86:598-612, 1998). For much of the modern era of medicine, postoperative pain management has been primarily accomplished by systemic opioids. Following thoracic surgery, intravenous opioids alone are often insufficient to adequately control pain and have been supplemented with the application of local anesthetics using various regional techniques. The most recent development in the evolution of local anesthetics is liposomal bupivacaine, a novel slow-release local anesthetic formulation. The local anesthetic is encapsulated utilizing an innovative delivery system known as DepoFoam®, without alteration to its molecular structure, and is steadily released over 72-96 h. At the University of Texas MD Anderson Cancer Center, our pain management strategy for thoracic procedures has undergone a major change over the last few years. For the better part of the last two decades, we have utilized epidurals for postoperative pain management in patients having thoracic surgery. With the combination of long-acting local anesthetics and regional techniques such as paravertebral and posterior intercostal nerve blocks, we have moved away from the use of catheters for postoperative pain management. At our institution, we have successfully incorporated long-acting local anesthetics into surgery-specific, evidence-based treatment protocols which utilize multimodal analgesia such as nonsteroidal anti-inflammatory drugs, N-methyl-D-aspartate (NMDA) antagonists, and peripheral nerve blocks. Though initial results are promising, further studies are warranted to better understand the efficacy and long-term safety profile of long-acting local anesthetics such as liposomal bupivacaine in the thoracic surgery population.