Anesthesia and analgesia: how does the role of anesthetists changes in the ERAS program for VATS lobectomy

Analgesic Efficacy and Safety of Intrathecal Morphine or Intercostal Levobupivacaine in Lung Cancer Patients after Major Lung Resection Surgery by Videothoracoscopy: A Prospective Randomized Controlled Trial

Background: Lung resection using video-assisted thoracoscopic surgery (VATS) improves surgical accuracy and postoperative recovery. Unfortunately, moderate-to-severe acute postoperative pain is still inherent to the procedure, and a technique of choice has not been established for the appropriate control of pain. In this study, we aimed to compare the efficacy and safety of intrathecal morphine (ITM) with that of intercostal levobupivacaine (ICL). Methods: We conducted a single-center, prospective, randomized, observer-blinded, controlled trial among 181 adult patients undergoing VATS (ISRCTN12771155). Participants were randomized to receive ITM or ICL. Primary outcomes were the intensity of pain, assessed by a numeric rating scale (NRS) over the first 48 h after surgery, and the amount of intravenous morphine used. Secondary outcomes included the incidence of adverse effects, length of hospital stay, mortality, and chronic post-surgical pain at 6 and 12 months after surgery. Results: There are no statistically significant differences between ITM and ICL groups in pain intensity and evolution at rest. In cough-related pain, differences in pain trajectories over time are observed. Upon admission to the PACU, cough-related pain was higher in the ITM group, but the trend reversed after 6 h. There are no significant differences in adverse effects. The rate of chronic pain was low and did not differ significantly between groups. Conclusions: ITM can be considered an adequate and satisfactory regional technique for the control of acute postoperative pain in VATS, compatible with the multimodal rehabilitation and early discharge protocols used in these types of surgeries.

The analgesic efficacy of erector spinae plane block versus paravertebral block in thoracic surgeries: a meta-analysis

Background

Acute postoperative pain after thoracic surgery might lead to chronic postsurgical pain (PSP), which lowers quality of life. The literature suggests thoracic paravertebral block (PVB) as a pain management approach. The ESPB (erector spinae plane block) is regarded to be an effective PVB alternative. The analgesic efficacy of the two analgesic therapies is controversial. The purpose of this study is to compare the analgesic efficacy of ESPB and PVB in preventing acute PSP.

Methods

We searched relevant articles in PubMed, Cochrane Library, Embase, Web of Science, and Google Scholar databases. The primary outcome was postoperative pain score, with secondary outcomes including analgesic consumption, the frequency of rescue analgesia, and postoperative nausea and vomiting.

Results

This meta-analysis included ten RCTs with a total of 670 patients. PVB significantly lowered the pain scores at movement at 12 h following surgery as compared to the ESPB. The PVB group used much less opioids within 24 h after surgery compared to the ESPB group. However, there were no significant differences between the groups in terms of postoperative rescue analgesia or in the incidence of postoperative nausea and vomiting (p > 0.05).

Conclusion

PVB produced superior analgesia than ESPB in patients who underwent thoracic surgeries. In addition, PVB demonstrated greater opioid sparing effect by consuming much less opioids.

Systematic review registration

This trial is registered on PROSPERO, number CRD42023412159.

Efficacy and safety of transcutaneous electrical acupoints stimulation for preoperative anxiety in thoracoscopic surgery: study protocol for a randomised controlled trial

INTRODUCTION

Preoperative anxiety occurs at a very high rate in patients undergoing video-assisted thoracoscopic surgery (VATS). Moreover, it will result in poor mental state, more analgesic consumptions, rehabilitation delay and extra hospitalisation costs. Transcutaneous electrical acupoints stimulation (TEAS) is a convenient intervention for pain control and anxiety reduction. Nevertheless, TEAS efficacy of preoperative anxiety in VATS is unknown.

METHODS AND ANALYSIS

This single-centre randomised sham-controlled trial will be conducted in cardiothoracic surgery department of the Yueyang Hospital of Integrated Traditional Chinese and Western Medicine in China. A total of 92 eligible participants with pulmonary nodules (size ≥8 mm) who are arranged for VATS will be randomly assigned to a TEAS group and a sham TEAS (STEAS) group in a 1:1 ratio. Daily TEAS/STEAS intervention will be administered starting on 3 days before the VATS and continued once per day for three consecutive days. The primary outcome will be the generalised anxiety disorder scale score change between the day before surgery with the baseline. The secondary outcomes will include serum concentrations of 5-hydroxytryptamine, norepinephrine and gamma-aminobutyric acid, intraoperative anaesthetic consumption, time to postoperative chest tube removal, postoperative pain, and length of postoperative hospital stay. The adverse events will be recorded for safety evaluation. All data in this trial will be analysed by the SPSS V.21.0 statistical software package.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai University of Traditional Chinese Medicine (approval number: 2021-023). The results of this study will be distributed through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04895852.

Erector spinae plane block, neuropathic pain and quality of life after video-assisted thoracoscopy surgery. Pilot, observational study

BACKGROUND

The erector spinae plane block (ESPB) is a valuable alternative for pain management after video-assisted thoracoscopy surgery (VATS). The incidence of postoperative chronic neuropathic pain (CNP) is high while the quality of life (QoL) after VATS remains unknown. We hypothesised that patients with ESPB would have a low incidence of acute and CNP and would report a good QoL up to three months after VATS.

METHODS

We conducted a single-centre prospective pilot cohort study from January to April 2020. ESPB after VATS was the standard practice. The primary outcome was the incidence of CNP three months postoperatively. Secondary outcomes included QoL assessed by the EuroQoL questionnaire three months after surgery and pain control at the Post-Anaesthesia Care Unit (PACU), 12 and 24 hours postoperatively.

RESULTS

We conducted a single-centre prospective pilot cohort study from January to April 2020. ESPB after VATS was the standard practice. The primary outcome was the incidence of CNP three months postoperatively. Secondary outcomes included QoL assessed by the EuroQoL questionnaire three months after surgery and pain control at the Post-Anaesthesia Care Unit (PACU), 12 and 24 hours postoperatively.

CONCLUSIONS

We conducted a single-centre prospective pilot cohort study from January to April 2020. ESPB after VATS was the standard practice. The primary outcome was the incidence of CNP three months postoperatively. Secondary outcomes included QoL assessed by the EuroQoL questionnaire three months after surgery and pain control at the Post-Anaesthesia Care Unit (PACU), 12 and 24 hours postoperatively.

Factors Associated with Early Discharge after Thoracoscopic Lobectomy: Results from the Italian VATS Group Registry

Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69−94] vs. 85 [73−98]), Forced Expiratory Volume (FEV1) % (92 [79−106] vs. 96 [82−109]), operative time (180 [141−230] vs. 160 [125−195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.

Factors Associated with Early Discharge after Thoracoscopic Lobectomy: Results from the Italian VATS Group Registry

Objective. There are limited data for estimating the risk of early discharge following thoracoscopic lobectomy. The objective was to identify the factors associated with a short length of stay and verify the influence of these variables in uncomplicated patients. Methods. We reviewed all lobectomies reported to the Italian VATS Group between January 2014 and January 2020. Patients and perioperative characteristics were divided into two subgroups based on whether or not they met the target duration of stay (≤ or >4 days). The association between preoperative and intraoperative variables and postoperative length of stay (LOS) ≤4 days was assessed using a stepwise multivariable logistic regression analysis to identify factors independently associated with LOS and factors related to LOS in uncomplicated cases. Results. Among 10,240 cases who underwent thoracoscopic lobectomy, 37.6% had a hospital stay ≤4 days. Variables associated with LOS included age, hospital surgical volume, Diffusion Lung CO % (81 [69–94] vs. 85 [73–98]), Forced Expiratory Volume (FEV1) % (92 [79–106] vs. 96 [82–109]), operative time (180 [141–230] vs. 160 [125–195]), uniportal approach (571 [9%] vs. 713 [18.5%]), bioenergy sealer use, and pain control through intercostal block or opioids (p < 0.001). Except for FEV1 and blood loss, all other factors emerged significantly associated with LOS when the analysis was limited to uncomplicated patients. Conclusions. Demographic, clinical, and surgical variables are associated with early discharge after thoracoscopic lobectomy. This study indicates that these characteristics are associated with early discharge. This result can be used in association with clinical judgment to identify appropriate patients for fast-track protocols.

Effectiveness of Perioperative Cardiopulmonary Rehabilitation in Patients With Lung Cancer Undergoing Video-Assisted Thoracic Surgery

Objectives

Patients with lung cancer pose a high risk of morbidity and mortality after lung resection. Those who receive perioperative cardiopulmonary rehabilitation (PRCR) have better prognosis. Peak oxygen consumption (peak VO₂), VO₂ at the ventilatory threshold (VO₂ at VT), and slope of minute ventilation to carbon dioxide production (V_E/V_CO2 slope) measured during pre-surgical cardiopulmonary exercise testing (CPET) have prognostic values after lung resection. We aimed to investigate the influence of individualized PRCR on postoperative complications in patients undergoing video-assisted thoracic surgery (VATS) for lung cancer with different pre-surgical risks.

Methods

This was a retrospective study. We recruited 125 patients who underwent VATS for lung cancer between 2017 and 2021. CPET was administered before surgery to evaluate the risk level and PRCR was performed based on the individual risk level defined by peak VO2, VO2 at VT, and VE/VCO2 slope, respectively. The primary outcomes were intensive care unit (ICU) and hospital lengths of stay, endotracheal intubation time (ETT), and chest tube insertion time (CTT). The secondary outcomes were postoperative complications (PPCs), including subcutaneous emphysema, pneumothorax, pleural effusion, atelectasis, infection, and empyema.

Results

Three intergroup comparisons based on the risk level by peak VO2 (3 groups), VO2 at VT (2 groups), and VE/VCO2 slope (3 groups) were done. All of the comparisons showed no significant differences in both the primary and secondary outcomes (p = 0.061–0.910).

Conclusion

Patients with different risk levels showed comparable prognosis and PPCs after undergoing CPET-guided PRCR. PRCR should be encouraged in patients undergoing VATS for lung cancer.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Incorporation of an intercostal catheter into a multimodal analgesic strategy for uniportal video-assisted thoracoscopic surgery: a feasibility study

Background

Well-controlled postoperative pain is essential for early recovery after uniportal video-assisted thoracoscopic surgery (UVATS). Conventional analgesia like opioids and thoracic epidural anaesthesia have been associated with hypotension and urinary retention. Intercostal catheters are a regional analgesic alternative that can be inserted during UVATS to avoid these adverse effects. This feasibility study aims to evaluate the postoperative pain scores and analgesic requirements with incorporation of an intercostal catheter into a multimodal analgesic strategy for UVATS.

Methods

In this observational study, 26 consecutive patients who underwent UVATS were administered a multilevel intercostal block and oral paracetamol. All of these patients received 0.2% ropivacaine continuously at 4 ml/h via an intercostal catheter at the level of the incision. Rescue analgesia including etoricoxib, gabapentin and opioids were prescribed using a pain ladder approach. Postoperative pain scores and analgesic usage were assessed. The secondary outcomes were postoperative complications, days to ambulation and length of stay.

Results

No technical difficulties were encountered during placement of the intercostal catheter. There was only one case of peri-catheter leakage. Mean pain score was 0.31 (range 0–2) on post-operative day 1 and was 0.00 by post-operative day 5. 16 patients (61.6%) required only oral rescue analgesia. The number of patients who required rescue non-opioids only increased from 1 in the first 7 months to 8 in the next 7 months. There were no cases of hypotension or urinary retention. Median time to ambulation was 1 day (range 1–2). Mean post-operative length of stay was 4.17 ± 2.50 days.

Conclusions

Incorporation of an intercostal catheter into a multimodal analgesia strategy for UVATS is feasible and may provide adequate pain control with decreased opioid usage.

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Subpleural multilevel intercostal continuous analgesia after thoracoscopic pulmonary resection: a pilot study

BACKGROUND

Sufficient pain control and rapid mobilisation after VATS are important to enhance recovery and prevent complications. Thoracic epidural analgesia (TEA) is the gold standard, but failure rates of 9-30% have been described. In addition, TEA reduces patient mobilisation and bladder function. Subpleural continuous analgesia (SCA) is a regional analgesic technique that is placed under direct thoracoscopic vision and is not associated with the mentioned disadvantages of TEA. The objective of this study was to assess surgical feasibility, pain control and patient satisfaction of SCA.

METHODS

Observational pilot study in patients who underwent VATS pulmonary resection and received SCA (n = 23). Pain scores (numeric rating scale 0-10) and patient satisfaction (5-point Likert scale) were collected on postoperative day (POD) 0-3. Secondary outcomes were the period of urinary catheter use and period to full mobilisation.

RESULTS

Placement of the subpleural catheter took an average of 11 min (SD 5) and was successful in all patients. Pain scores on POD 0-3 were 1.2 (SD 1.2), 2.0 (SD 1.9), 1.7 (SD 1.5) and 1.2 (SD 1.1) respectively. On POD 0-3 at least 79% of patients were satisfied or very satisfied on pain relief and mobilisation. The duration of subpleural continuous analgesia was 4 days (IQR 3-5, range 2-11). Urinary catheters were used zero days (IQR 0-1, range 0-6) and full mobilisation was achieved on POD 2 (IQR 1-2, range 1-6).

CONCLUSION

Subpleural continuous analgesia in VATS pulmonary resection is feasible and provides adequate pain control and good patient satisfaction.

TRIAL REGISTRATION

This pilot study was not registered in a trial register.