Liposomal Bupivacaine Is Good Alternative to Thoracic Epidural Analgesia for Patients Undergoing Minimally Invasive Lung Resection

Liposomal bupivacaine (LB) has been compared with thoracic epidural analgesia (TEA) in four thoracic surgery studies, but none involved thoracoscopically witnessed intercostal injection. Direct vision by thorascope confirms delivery of the drug to the subpleural depth and avoids missing an intercostal space.

Namrata Patil, MD, MPH, director of the Thoracic Intermediate Care Unit in the Division of Thoracic Surgery at Brigham and Women’s Hospital, Anupama Singh, MD, a research fellow in cardiac and thoracic surgery in the Department of Surgery, and colleagues recently completed a retrospective study comparing TEA with injection of LB under direct witness in patients undergoing minimally invasive lung resection.

In the Journal of Thoracic Disease, they report LB intercostal block reduced opioid use 48 hours postoperatively and was associated with fewer postoperative complications and shorter hospital stay.


The study included all 391 patients who underwent minimally invasive lung resection over an eight-month period at the Brigham. 63% were female and the median age at surgery was 68 (range, 26–89). 326 patients (83%) patients received LB.

A nurse asked patients to assess their pain using a visual analog scale (1–10) in the post-anesthesia care unit (PACU), 12 and 24 hours postoperatively and at 48 hours if not discharged sooner.

Opioid Consumption

The primary outcome was postoperative opioid consumption, calculated as morphine milligram equivalents (MME). Median MME was:

At 24 hours

  • LB group—45 (range, 0–440)
  • TEA group—38 (range, 0–165) (P=0.41)

At 48 hours

  • LB group—20 (range, 0–244)
  • TEA group—30 (range, 0–143) (P=0.03)

The use of non-narcotic analgesic adjuncts was similar in the two groups.

Secondary Outcomes

The secondary outcomes were postoperative pain, adverse events, and length of hospital stay.

  • Pain scores—There was no difference between groups in pain scores in the PACU (P=0.107) or at 12 hours postoperatively (P=0.38). At 24 hours, TEA patients reported a median score of 5 (range, 0–10) versus 4 (range, 0–10) reported by LB patients (P=0.03). At 48 hours, the respective median scores were 3 (range, 0–10) and 2 (range, 0–8) (P=0.001).
  • Length of stay—The median length of stay was 2 days for patients who received LB versus 4 days for the TEA group (P<0.001). On multivariable analysis, TEA was one of the factors independently associated with longer stay (β, 1.19; P<0.001).
  • Adverse events—22 patients who received TEA (20%) and 57 who received LB (18%) developed at least one postoperative complication (P=0.004). The incidence of Clavien–Dindo grade II complications was significantly higher in the TEA group (31% vs. 15%; P=0.004). There were no differences between the groups in rates of grades III and IV complications.


These results are especially important given ongoing efforts to reduce opioid use postoperatively. Placement of LB intercostal blocks under direct vision should be considered when possible for pain management after minimally invasive lung resection.

Leave a Reply