Effects of Different Analgesic Modalities on Pain Relief and Safety After Minimally Invasive Esophagectomy: A Randomized Controlled Clinical Study

Background Effective postoperative pain management is crucial for Enhanced Recovery After Surgery (ERAS) in minimally invasive esophagectomy (MIE) for oesophageal cancer, as inadequate pain control can impair organ function and increase complications such as pneumonia. Current guidelines recommend multimodal analgesia, including opioids, NSAIDs, acetaminophen, regional anaesthesia, and patient-controlled intravenous analgesia (PCIA), but the optimal combination remains unclear. Clinical observations suggest NSAIDs alone may be insufficient, while opioids can cause gastrointestinal side effects. This study compares the analgesic efficacy, gastrointestinal recovery, and safety of different regimens, and evaluates the clinical effectiveness of preemptive NSAIDs administration in MIE patients. Methods Ninety-three patients undergoing minimally invasive esophagectomy (MIE) from December 2022 to December 2024 were randomized into three groups (1:1:1). Group A (Routine NSAIDs) received intravenous flurbiprofen axetil postoperatively; Group B (Preemptive NSAIDs) received flurbiprofen axetil preoperatively and postoperatively; Group C (Opioid-based PCIA) received postoperative analgesia via mechanical analgesic pumps containing sufentanil and ondansetron. All patients had intraoperative and postoperative (days 1–3) ropivacaine wound infiltration. Primary outcomes were maximum and average Visual Analogue Scale (VAS) pain scores on postoperative days 1–3. Secondary outcomes included time to first flatus and defecation, and rates of postoperative nausea, vomiting, and abdominal distension. Results All analgesic regimens provided satisfactory postoperative analgesia. Pain scores were similar among groups on days 1 and 3 (P > 0.05), but Group B reported lower pain than Group A on day 2 (3.41 ± 0.35 vs. 4.53 ± 0.39, P < 0.05), indicating benefit from preemptive NSAIDs. Gastrointestinal recovery was faster in NSAIDs-based groups (A: 40.90 ± 3.27 h, B: 35.53 ± 3.79 h) than in the opioid-based group (C: 59.58 ± 5.51 h; P < 0.01), with defecation also earlier in A and B (A: 73.02 ± 4.89 h, B: 57.19 ± 8.22 h) than C (83.46 ± 7.75 h; P < 0.05). Group C had more gastrointestinal adverse events, but not significantly (P > 0.05). Conclusion Both NSAIDs-based analgesia and opioid-based PCIA effectively provided satisfactory pain control after MIE for esophageal cancer. However, NSAIDs-based regimens offered faster gastrointestinal recovery and fewer gastrointestinal adverse effects, potentially facilitating improved postoperative recovery. Preemptive NSAIDs administration provided only transient analgesic improvement on postoperative day 2, with limited clinical significance. Further studies are required to confirm these findings. Clinicians should individualise analgesic regimens by considering patient characteristics and medication profiles to enhance postoperative recovery and minimise adverse events after esophagectomy.