Perioperative analgesic strategies for video-assisted thoracoscopic lobectomy: a systematic review and meta-analysis.

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) lobectomy is the standard of care for early-stage lung cancer, yet 20-30% of patients still experience moderate-to-severe acute postoperative pain. A wide range of perioperative analgesic strategies-regional blocks, systemic adjuncts, cryoanalgesia, and multimodal combinations-have been evaluated, but their comparative effects on clinically meaningful endpoints such as postoperative complications remain uncertain. The aim of this systematic review and meta-analysis was to evaluate the comparative efficacy and safety of perioperative analgesic strategies for VATS lobectomy.

METHODS

We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) (PROSPERO CRD420251186565), following the PRISMA 2020 statement. PubMed/MEDLINE and Web of Science Core Collection were searched from 1 January 2010 to 26 June 2026. Two reviewers independently screened records, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool per outcome. Postoperative complications were pooled as risk ratios (RR) with 95% confidence intervals (CIs) using a random-effects model with restricted maximum-likelihood (REML) estimation. Studies were grouped by intervention type for subgroup analysis. Sensitivity was assessed with leave-one-out analysis.

RESULTS

Seven trials (n=505) met inclusion criteria. The evidence base was clinically heterogeneous: included comparisons encompassed regional technique variations [paravertebral block (PVB), serratus anterior plane block (SAPB), intercostal nerve block (ICNB), and their combinations], systemic adjunctive analgesics (nefopam), and intercostal cryoanalgesia. Only three trials reported usable complication data for quantitative synthesis (n=245). The overall pooled RR for postoperative complications was 0.84 (95% CI: 0.65-1.08; P=0.18), but this estimate was dominated by a single trial (Koliakos 2025, 75.2% weight). Between-study heterogeneity was absent (I2=0%, τ2=0; Q=0.39, df =2, P=0.82). Subgroup analyses by intervention class (regional techniques, systemic adjuncts, cryoanalgesia) did not yield statistically significant pooled estimates. Leave-one-out exclusion of the largest study shifted the point estimate to RR 0.95 (95% CI: 0.57-1.58), confirming strong dependence on a single trial. With fewer than 10 studies, formal publication bias assessment was not performed.

CONCLUSIONS

The available evidence on perioperative analgesic strategies for VATS lobectomy consists of small, heterogeneous trials comparing diverse interventions. No single strategy has been shown to consistently reduce postoperative complications. The evidence base is insufficient to guide clinical practice. Adequately powered, multicentre RCTs with standardised interventions, composite complication endpoints, and extended follow-up are needed.