Thoracic Epidural Analgesia in Major Cancer Surgery: An Update

Background and Objectives: Postoperative pain after major cancer surgery contributes to pulmonary, cardiovascular, metabolic, and functional complications. Thoracic epidural analgesia [TEA] has traditionally been considered the standard analgesic technique for open thoracic and upper abdominal oncologic surgery, although minimally invasive techniques and ERAS pathways have prompted a re-evaluation of its role. Methods: This narrative review summarizes evidence from PubMed and MEDLINE published between 1995 and June 2026, emphasizing randomized trials, systematic reviews, meta-analyses, large observational studies, and selected work by the authors. Results: TEA provides superior dynamic analgesia and reduces opioid consumption, facilitating early mobilization, respiratory recovery, and gastrointestinal function. By attenuating sympathetic and neuroendocrine stress responses, it may contribute to reductions in pulmonary complications, ileus, insulin resistance, and delirium, particularly in elderly, frail, sarcopenic, and high-risk patients. Limitations include hypotension, urinary retention, technical failure, and rare but potentially serious complications such as epidural hematoma. In minimally invasive surgery, alternative regional techniques and multimodal opioid-sparing analgesia often achieve comparable postoperative outcomes with fewer hemodynamic effects, supporting selective rather than routine TEA use. Although neuraxial techniques may have immunomodulatory effects and potentially preserve immune function, randomized studies have not demonstrated a reduction in cancer recurrence or an improvement in long-term survival. Conclusions: TEA remains an effective analgesic strategy for selected patients undergoing major open thoracic and upper abdominal cancer surgery. In contemporary perioperative practice, its use should be individualized according to surgical invasiveness, patient characteristics and expected postoperative pain. Current evidence supports TEA primarily as a perioperative analgesic and recovery strategy, with no established oncologic benefit.