Epidural for mini-invasive thoracic surgery: do we need a sledgehammer to crack a nut?

Postoperative Pain Intensity After Single-port, Double-port, and Triple-port Video-assisted Lung Lobectomy: A Three-arm Parallel Randomized Clinical Trial

OBJECTIVE

Video-assisted thoracic surgery (VATS) has evolved from a multiport approach to a one-port approach to reduce the degree of surgical trauma. However, there is no consensus on the number of incisions leading to less postoperative pain. Early postoperative pain was compared after three technical variants of VATS lobectomy under multimodal analgesia, including thoracic epidural analgesia.

DESIGN

This study was designed as a prospective, randomized, controlled clinical trial with three parallel arms.

SETTING

Single-center study.

PARTICIPANTS

A total of 112 adult patients with ASA statuses I to III who were scheduled to undergo elective VATS lobectomy for early-stage non-small cell lung cancer were enrolled.

INTERVENTIONS

Patients were randomly assigned to one of three groups: single-port, double-port, and triple-port VATS lobectomy. The same postoperative analgesia protocol was used in each group.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was postoperative pain intensity at rest and when coughing within the first 72 hours after surgery. The secondary outcomes were cumulative opioid consumption and the composite rate of postoperative complications. A total of 112 patients were enrolled in the study, 91 of whom completed the study protocol. There were no significant differences between the study groups in terms of pain intensity either at rest (p = 0.319) or when coughing (p = 0.202). There was no difference in the incidence of postoperative complications.

CONCLUSIONS

This study revealed no differences in pain intensity in the early postoperative period between three different technical variants of VATS lobectomy when an analgesia protocol based on thoracic epidural anesthesia was used.

Bilateral Ultrasound-Guided Erector Spinae Plane Block for Pectus Excavatum Surgery: A Retrospective Propensity-Score Study

OBJECTIVE

Pectus excavatum (PE) repair is burdened by severe postoperative pain. This retrospective study aimed to determine whether the analgesic effect of ultrasound-guided erector spinae plane block (ESPB) plus standard intravenous analgesia (SIVA) might be superior to SIVA alone in pain control after PE surgical repair via Ravitch or Nuss technique.

DESIGN

A retrospective cohort study.

SETTING

At a university hospital.

PARTICIPANTS

All participants were scheduled for surgical repair of PE.

INTERVENTIONS

From January 2017 to December 2019, all patients who received ESPB plus SIVA or SIVA alone were investigated retrospectively. A 2:1 propensity-score matching analysis considering preoperative variables was used to compare analgesia efficacy in 2 groups. All patients received a 24-hour continuous infusion of tramadol, 0.1 mg/kg/h, and ketorolac, 0.05 mg/kg/h, via elastomeric pump, and morphine, 2 mg, intravenously as a rescue drug. The ESPB group received preoperative bilateral ESPB block. Postoperative pain, reported using a numerical rating scale at 1, 12, 24, and 48 hours after surgery; the number of required rescue doses; total postoperative morphine milligram equivalents consumption; and the incidence of postoperative nausea and vomit were analyzed.

MEASUREMENT AND MAIN RESULTS

A total of 105 patients were identified for analysis. Propensity-score matching resulted in 38 patients in the SIVA group and 19 patients in the ESPB group. Postoperative pain, the number of rescue doses, and postoperative nausea and vomit incidences were lower in the ESPB group (p < 0.005).

CONCLUSIONS

Erector spinae plane block may be an effective option for pain management after surgical repair of PE as part of a multimodal approach. This study showed good perioperative analgesia, opioid sparing, and reduced opioid-related adverse effects.

Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial

OBJECTIVE

Several nerve block procedures are available for post-thoracotomy pain management.

DESIGN

In this randomized trial, the authors aimed to determine whether the analgesic effect of preoperative ultrasound-guided erector spinae plane block (ESPB) might be superior to that of intraoperative intercostal nerve block (ICNB) in pain control in patients undergoing minithoracotomy.

SETTING

University hospital.

PARTICIPANTS

Sixty consecutive adult patients scheduled to undergo minithoracotomy for lung resection were enrolled.

INTERVENTIONS

Patients were allocated randomly in a 1:1 ratio to receive either single-shot ESPB or ICNB.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the intensity of postoperative pain at rest, assessed with the numeric rating scale (NRS). The secondary outcomes were (1) dynamic NRS values (during cough); (2) perioperative analgesic requirements; (3) patient satisfaction, on the basis of a verbal scale (Likert scale); and (4) respiratory muscle strength, considering the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) variation from baseline. The ESPB group showed lower postoperative static and dynamic NRS values than the ICNB group (p < 0.05). Total remifentanil consumption and requirements for additional analgesics were lower in the ESPB group (p < 0.05). Patient satisfaction was higher in the ESPB group (p < 0.001). A significant overall time effect was found in MIP and MEP variation (p < 0.001); ESPB values were higher at all points, reaching a statistically significant level at the first and sixth hours for MIP, and at the first, 12th, 24th, and 48th hours for MEP (p < 0.05).

CONCLUSIONS

ESPB was demonstrated to provide superior analgesia, lower perioperative analgesic requirements, better patient satisfaction, and less respiratory muscle strength impairment than ICNB in patients undergoing minithoracotomy.