Do we still need thoracic epidural analgesia in minimally invasive lung surgery?

Homma and co-workers nicely describe how their department-wide transition from multi- to uniportal video-assisted thoracoscopic surgery (VATS) was associated with decreased complications and less neuropathic pain, while concomitantly observing that thoracic epidural analgesia (TEA) apparently provides no true benefits for pain-relief in minimally-invasive lung surgery when compared to isolated intercostal nerve blockade (1). Even though the overall better outcome in their uniportal group (blood loss 1 vs. 30 mL; P=0.0010, complications 23.9% vs. 40.9%; P=0.048 and postoperative neuropathic pain 32.4% vs. 52.1%; P=0.027) might be at least partially biased, as a single surgeon performed all uniportal cases while a number of different surgeons operated in multiportal fashion, the broader question of optimal, procedure-oriented pain-relief is raised.

The past few years brought us not just a delve of technical innovations, from VATS and robotic-assisted thoracoscopic surgery (RATS) segmentectomy for early lung cancer (2) to non-intubated major lung surgery (3), but generally led to more patient-centric delivery of medical care. ERAS (enhanced recovery after surgery) concepts gained major traction in thoracic surgery since Tim Batchelor first published a list of 45 items of evidence-based procedures to improve overall outcome of patients undergoing pulmonary resection (4). Pain-relief was one of the central topics that were addressed, stressing the importance of standardized multimodal approaches that should include a form of good regional anesthesia with the aim of reducing postoperative opioid use. Furthermore, he underlines that “paravertebral blockade provides equivalent analgesia to TEA with evidence of a better side-effect profile”.

This is well in line with the results of a procedure-specific postoperative pain management (PROSPECT) based publication by members of the European Society of Regional Anesthesia & Pain Therapy (ESRA) (5). Herein, 69 randomized controlled trials and two reviews published in English Language between 2010–2021 were analyzed to determine optimal pain management in patients undergoing video-assisted thoracoscopic surgery. They conclude by recommending regional analgesic techniques such as paravertebral block and erector spinae plane block, while suggesting to use Serratus anterior plane block as a second choice and avoiding TEA altogether for postoperative analgesia. Key for this recommendation were a total of 7 studies investigating effectiveness of TEA in VATS. In one of these, Zejun and co-workers (6) demonstrated superior pain control for isolated TEA vs. PCA, while the same was not true if basic analgesia was accompanied by surgical intercostal nerve blockade (7) or in head-to-head comparisons of TEA and paravertebral blockade (8-10). A further meta-analysis suggested no true evidence to recommend either TEA or paravertebral blockade from a pure pain-control point of view (11), with the latter having a lower incidence of both urinary retention and hypotension. Diverging from earlier PROSPECT recommendations for post thoracotomy analgesia (12), at present TEA is not encouraged in VATS, even as a second-line option, due to its risks that may further impede early mobilization. This is in line with a very recent publication by Yamazaki and co-workers, who describe how intraoperative intercostal nerve blockade performed by surgeons leads to pain relief equivalent with TEA in VATS (13).

Ideally, minimally-invasive surgery should not just consist of increasingly smaller and fewer incisions, but follow a more holistic approach to delivering medical care by reducing the overall trauma a patient faces during treatment. In the end, Homma et al. describe how the benefits of an increasingly smaller procedural trauma, by transitioning from multiportal to uniportal VATS, add up with the benefits of foregoing TEA altogether. As we dispose of very good alternatives to TEA that are less prone to complications, we should try to widely adopt either transcutaneous or intraoperative paravertebral blockade and/or erector spinae plane blocks into our daily routine, with the added benefit of shorter induction times.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2022-14/coif). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Homma T, Shimada Y, Tanabe K. Decreased postoperative complications, neuropathic pain and epidural anesthesia-free effect of uniportal video-assisted thoracoscopic anatomical lung resection: a single-center initial experience of 100 cases. J Thorac Dis 2022;14:3154-66. [Crossref]
2. Jian Z, Li C, Feng X, et al. Robotic versus thoracoscopic combined anatomic subsegmentectomy for early-stage lung cancer: early results of a cohort study. J Thorac Dis 2022;14:1441-9. [Crossref] [PubMed]
3. Gonzalez-Rivas D. Uniportal thoracoscopic surgery: from medical thoracoscopy to non-intubated uniportal video-assisted major pulmonary resections. Ann Cardiothorac Surg 2016;5:85-91. [Crossref] [PubMed]
4. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg 2019;55:91-115. [Crossref] [PubMed]
5. Feray S, Lubach J, Joshi GP, et al. PROSPECT guidelines for video-assisted thoracoscopic surgery: a systematic review and procedure-specific postoperative pain management recommendations. Anaesthesia 2022;77:311-25. [Crossref] [PubMed]
6. Zejun N, Wei F, Lin L, et al. Improvement of recovery parameters using patient-controlled epidural analgesia for video-assisted thoracoscopic surgery lobectomy in enhanced recovery after surgery: A prospective, randomized single center study. Thorac Cancer 2018;9:1174-9. [Crossref] [PubMed]
7. Tseng WC, Lin WL, Lai HC, et al. Fentanyl-based intravenous patient-controlled analgesia with low dose of ketamine is not inferior to thoracic epidural analgesia for acute post-thoracotomy pain following video-assisted thoracic surgery: A randomized controlled study. Medicine (Baltimore) 2019;98:e16403. [Crossref] [PubMed]
8. Okajima H, Tanaka O, Ushio M, et al. Ultrasound-guided continuous thoracic paravertebral block provides comparable analgesia and fewer episodes of hypotension than continuous epidural block after lung surgery. J Anesth 2015;29:373-8. [Crossref] [PubMed]
9. Yeap YL, Wolfe JW, Backfish-White KM, et al. Randomized Prospective Study Evaluating Single-Injection Paravertebral Block, Paravertebral Catheter, and Thoracic Epidural Catheter for Postoperative Regional Analgesia After Video-Assisted Thoracoscopic Surgery. J Cardiothorac Vasc Anesth 2020;34:1870-6. [Crossref] [PubMed]
10. Huang QW, Li JB, Huang Y, et al. A Comparison of Analgesia After a Thoracoscopic Lung Cancer Operation with a Sustained Epidural Block and a Sustained Paravertebral Block: A Randomized Controlled Study. Adv Ther 2020;37:4000-14. [Crossref] [PubMed]
11. Harky A, Clarke CG, Kar A, et al. Epidural analgesia versus paravertebral block in video-assisted thoracoscopic surgery. Interact Cardiovasc Thorac Surg 2019;28:404-6. [Crossref] [PubMed]
12. Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008;107:1026-40. [Crossref] [PubMed]
13. Yamazaki S, Koike S, Eguchi T, et al. Preemptive Intercostal Nerve Block as an Alternative to Epidural Analgesia. Ann Thorac Surg 2022;114:257-64. [Crossref] [PubMed]