Liposomal Bupivacaine TPVB Not Superior to Ropivacaine in Thoracoscopic Surgery

Key Takeaways

• The primary activity-pain outcome differed among groups because high-dose liposomal bupivacaine was associated with lower activity-pain burden than low-dose liposomal bupivacaine, not because either liposomal strategy was superior to ropivacaine.
• Rest-pain burden was similar across groups, and lower opioid use with high-dose liposomal bupivacaine was seen versus low-dose liposomal bupivacaine but not versus ropivacaine.
• Postoperative recovery and adverse events were similar across groups, and the investigators concluded liposomal bupivacaine with thoracic paravertebral block was not superior to ropivacaine.

In a 105-patient randomized comparison after single-port thoracoscopic lung surgery, investigators compared low-dose liposomal bupivacaine, high-dose liposomal bupivacaine, and ropivacaine for postoperative analgesia. Activity-pain burden from 1 to 72 hours differed across groups, providing the trial's prespecified positive result. That difference reflected lower activity-pain burden with high-dose liposomal bupivacaine than with low-dose liposomal bupivacaine, although the pain reduction was clinically limited. Neither liposomal bupivacaine regimen, however, was superior to ropivacaine on the clinically relevant comparison.

The trial enrolled 105 patients undergoing video-assisted single-port thoracoscopic lung surgery and randomized them 1:1:1 to low-dose liposomal bupivacaine, high-dose liposomal bupivacaine, or ropivacaine. All patients received a preoperative ultrasound-guided thoracic paravertebral block at the T5/6 level. The prespecified primary outcome was the area under the curve of numeric rating scale pain at activity from 1 to 72 hours postoperatively. Secondary outcomes included area under the curve for rest pain and cumulative opioid consumption through 72 postoperative hours. Pain scores at rest and with activity were also measured at 1, 6, 24, 48, and 72 hours, setting up the subsequent group comparisons.

For the primary endpoint, activity-pain area under the curve differed significantly among groups, with an overall p value of 0.0092. High-dose liposomal bupivacaine produced a lower activity-pain area under the curve than low-dose liposomal bupivacaine, with p = 0.0071. By contrast, the same comparison did not show an advantage over ropivacaine, keeping the main between-treatment interpretation narrow. Area under the curve for rest pain did not differ significantly among groups, and group-by-time interactions for pain at rest and activity were not significant. The efficacy pattern remained limited to the higher-dose versus lower-dose liposomal comparison.

Cumulative opioid consumption at 24, 48, and 72 hours was lower with high-dose liposomal bupivacaine than with low-dose liposomal bupivacaine. Those time-point comparisons were significant at p < 0.017, but opioid use was not lower versus ropivacaine. Postoperative recovery and adverse events did not differ across the three groups. These secondary results paralleled the primary finding by favoring the higher liposomal dose only against the lower dose. Overall, the investigators concluded that liposomal bupivacaine combined with thoracic paravertebral block was not superior to ropivacaine for postoperative analgesia after single-port thoracoscopic lung resection in this trial.