Serratus Anterior Block for Long-Term Post-Thoracoscopy Pain Management

The effect of different regional analgesia methods on chronic pain after thoracic surgery

Introduction

Chronic postsurgical pain (CPSP) is defined as pain persisting for ≥ 3 months after surgery, severely impairing patients' long-term daily activities and quality of life.

Aim

To evaluate the effects of various regional analgesia methods, including thoracic epidural (TE), serratus anterior plane (SAP) block, rhomboid intercostal block (RIB) and paravertebral block (PVB), on the incidence of chronic post-thoracic surgery pain.

Material and methods

A total of 489 patients (240 thoracotomy, 249 VATS) were included in the analysis. The primary outcome measure was the VAS score (postoperative 6th month), while the secondary outcome measures were the LANSS score (postoperative 6th month), the use of analgesic medication and descriptive information.

Results

In thoracotomy patients, VAS scores were statistically significantly lower in patients who underwent RIB and SAP block compared to those who underwent TE and patient-controlled anesthesia (PCA). LANSS scores did not differ between the RIB, SAP and TE groups, while higher scores were found in the PCA group. After VATS, VAS scores were statistically significantly lower in patients who underwent RIB, SAP and PVB block compared to the PCA group. LANSS scores were statistically significantly lower in the RIB and SAP block groups than in the PVB and PCA groups.

Conclusions

This study found that patients who received regional anesthesia had lower LANSS scores and VAS values, indicative of neuropathic pain reduction, following thoracotomy and VATS procedures.

Modified pericostal suture technique to reduce postoperative pain and provide optimum anatomic restoration after conversion of minimally invasive thoracic surgery to thoracotomy

Minimally invasive thoracic techniques often need to be converted to open thoracotomy. Thoracotomy is associated with severe postoperative pain in 50% of the patients, and this situation can be maintained for a prolonged period. Many efforts have been made to avoid this complication. We propose an easy and fast thoracotomy closure technique to avoid nerve entrapment at the time of chest closure suitable for cases of conversion to thoracotomy after a minimally invasive attempt. The proposed method effectively avoids interference with the intercostal nerve, which remains intact and restores the anatomy of the intercostal space. Efforts to decrease postoperative pain are vital. Thoracic surgeons are the principal health professionals able to deal with operative factors and postoperative pain management. We believe that the use of this easy and fast technique can facilitate excellent anatomic repositioning of the ribs alongside nerve sparing.

Prevalence and Predictors of Chronic Postsurgical Pain After Video-Assisted Thoracoscopic Surgery: A Systematic Review and Meta-analysis

INTRODUCTION

Determining the prevalence of chronic postsurgical pain (CPSP) after video-assisted thoracoscopic surgery (VATS) and identifying CPSP predictors should improve the prognosis of patients undergoing VATS. Although several studies have investigated predictors of CPSP after VATS, there were significant dissimilarities in the findings due to the confounding of predictors.

METHODS

PubMed, Cochrane, MEDLINE, Web of Science, Chinese Biomedical Literature, and China National Knowledge Infrastructure databases were comprehensively searched using the Medical Subject Headings terms "pain, postoperative," "thoracic surgery, video-assisted," and all related free terms from inception until March 27, 2022. The Stata metaprop package was used to comprehensively analyze the incidence of CPSP following VATS. Furthermore, the pooled odds ratios (OR) or the standardized mean differences (SMD) and their corresponding 95% confidence intervals (95% CI) were calculated, and qualitative analyses were performed for predictors that could not be assessed quantitatively to evaluate the effects of the included risk factors on the occurrence of CPSP. Unadjusted odds ratios were utilized to consider the impact of non-significant estimates if the original study did not report them.

RESULTS

Of the 4302 studies, 183 were considered eligible, and 17 were finally included in this study. The overall incidence of CPSP after VATS was 35.3% (95% CI 27.1-43.5%). The qualitative synthesis results revealed that female sex, age, and acute postoperative pain were definite predictors of CPSP after VATS. The number of ports, operation time, duration of drainage, and insufficient analgesia were also considered predictors. Consistent, quantitative synthesis results also showed that the aforementioned predictors were closely related to the occurrence of CPSP after VATS. Only by quantitative analysis, postoperative chemotherapy and an educational level less than junior school were also risk factors for CPSP. Other predictors displayed no evidence or unclear evidence of association with CPSP after VATS.

CONCLUSION

This study preliminarily determined the incidence of CPSP after VATS based on the existing literature. Female sex, age, and acute pain were identified as risk factors for CPSP after VATS, and other potential risk factors were also identified and analyzed. However, as a result of the inclusion of retrospective studies and inevitable limitations in this systematic review and meta-analysis, the results of this study still need to be verified by large-scale prospective clinical studies.

TRIAL REGISTRATION

CRD42022323179.

Nomogram prediction of chronic postsurgical pain in patients with lung adenocarcinoma after video-assisted thoracoscopic surgery: A prospective study

Chronic postsurgery pain (CPSP) refers to persistent or repeated pain around the incision after surgery. Different from acute postoperative pain, the persistence of CPSP seriously affects the quality of life of patients. CPSP has a considerable global impact due to large surgical volumes. Although the development of video-assisted thoracoscopy (VATS) has reduced the risk of CPSP, it still seriously affects patients' quality of life. Clinical recognition of CPSP at an early stage is limited; therefore, we aimed to develop and validate a nomogram to identify the significant predictive factors associated with CPSP after VATS in patients with lung adenocarcinoma. We screened 137 patients with invasive adenocarcinoma of the lung from among 312 patients undergoing VATS. In this prospective study, patients were divided into the CPSP (n = 52) and non-CPSP (n = 85) groups according to the occurrence of CPSP. Relevant information was collected 1 day before surgery and 1-3 days after surgery, and the occurrence of CPSP was followed up by telephone at 3 months after surgery. Data on clinical characteristics and peripheral blood leukocyte miRNAs were used to establish a nomogram for predicting CPSP using least absolute shrinkage and selection operator (LASSO) regression methods. The area under curve (AUC) was used to determine the recognition ability of the nomograms. The model was subjected to correction and decision curve analyses. Four variables-body mass index (BMI), history of chronic pain, miR 550a-3p, and visual analog scale (VAS) score on postoperative day 2 (VAS2d)-were selected according to LASSO regression to build the nomogram. The nomogram demonstrated adequate calibration and discrimination in the prediction model, with an AUC of 0.767 (95% confidence interval: 0.679-0.856). The calibration plot showed the best fit between model predictions and practical observations, suggesting that the use of the proposed nomogram to predict CPSP is beneficial. A nomogram consisting of BMI, history of chronic pain, miR 550a-3p, and VAS2d predicted the risk of CPSP after VATS in patients with lung adenocarcinoma.

A Comparison of the Differences in Postoperative Chronic Pain Between Video-Assisted and Robotic-Assisted Approaches in Thoracic Surgery

Background and objective In the last decade, there has been significant evolution in thoracic surgery with the advent of robotic surgery. In this study, we aimed to evaluate the incidence of postoperative chronic pain (for six months and beyond) in robotic and video-assisted approaches to analyze the long-term effects of the two different techniques. Methods This was a retrospective study involving 92 patients who underwent various thoracic operations between six months and two years preceding the study. Patients were classified into two groups based on the type of surgery: video-assisted (VATS) (n=51), and robotic-assisted (RATS) (n=41) thoracoscopic Surgery. We employed the EuroQol (EQ-5D-5L) questionnaire to assess the utility values in terms of five quality-of-life measures (self-care, pain/discomfort, mobility, anxiety/depression, and usual activities). Results In the VATS group, the median age was 68 years while it was 57 years in the RATS group (p=0.001). A higher proportion of patients in the VATS group had anatomical lung resection (lobectomy) compared to the RATS group: 61.2 vs. 41.6% respectively (p=0.005). However, the groups were well-matched on other patient characteristics such as relevant past medical history, underlying disease pathology, and final disease staging (if malignant), with no significant differences between groups observed regarding these traits. In the VATS group, 62.7% of patients were pain-free at the time of the questionnaire-based evaluation compared to 51.2% in the RATS group. Additionally, 25.5% vs. 39% of patients had mild pain in the VATS and RATS groups respectively. Neither of these differences was statistically significant. Conclusion Patients who undergo RATS are known to have better recovery and less pain compared to those who have VATS in the immediate postoperative period. However, our results did not find RATS to be superior to VATS in terms of long-term pain. Additionally, robotic surgery is associated with higher hospital costs. In light of these findings, further comparative studies between the two approaches are recommended, while strategies to reduce postoperative pain and financial cost should continue to be explored.