Postoperative analgesia following robot-assisted thoracic surgery for mediastinal disease: retrospective comparative study of general anesthesia alone, combined with epidural analgesia, and with ultrasound-guided thoracic paraspinal block

Abstract

Background Recently, robot-assisted thoracic surgery has been increasingly performed for mediastinal disease. However, appropriate postoperative analgesic methods have not been evaluated. Methods We retrospectively studied patients who underwent robot-assisted thoracic surgery for mediastinal disease at a single university hospital between January 2019 and December 2021. Patients were performed either general anesthesia alone, general anesthesia combined with thoracic epidural anesthesia, or general anesthesia combined with ultrasound-guided thoracic block. Patients were divided into three groups [non-block (NB), thoracic epidural analgesia (TEA), and thoracic paraspinal block (TB)] according to postoperative analgesic methods, and they compared with terms of postoperative pain scores by using numerical rating scale (NRS) at 0, 3, 6, 12, 18, 24, and 48 h. Additionally, rescue supplemental analgesic within 24 h, side effects of anesthesia such as respiratory depression, hypotension, postoperative nausea and vomiting, pruritus and urinary retention, time to ambulation after surgery, and hospital stay after surgery were also compared among the three groups. Results Data from 169 patients (Group NB: 25, Group TEA: 102, and Group TB: 42) were progressed to the analysis. Postoperative pain scale at 6 and 12 h was significantly lower in Group TEA than NB (1.2±1.6 vs . 2.4±1.8, P<0.01; and 1.2±1.5 vs . 2.2±1.7, P=0.018, respectively). There were no differences in pain scores between Groups TB and TEA at any point. The incidence of patients using rescue analgesics within 24 h was significantly different between groups [Group NB: 15/25 (60%), Group TEA: 30/102 (29.4%), Group TB: 25/42 (59.5%), P=0.01]. For postoperative side effects, only the number of patients complaining of postoperative nausea and vomiting for 24 h after surgery differed significantly between groups [Group NB: 7/25 (28%), Group TEA: 19/102 (18.6%), Group TB: 1/42 (2.4%), P=0.01]. Conclusions TEA provided better analgesia after robot-assisted thoracic surgery for mediastinal disease than NB as indicated by lower pain scores and fewer rescue analgesic requirements. However, the frequency of postoperative nausea and vomiting was lowest in Group TB of all the groups. Thus, TBs might also provide adequate postoperative analgesia following robot-assisted thoracic surgery for mediastinal disease.

Comparison of Thoracic Paravertebral Block and Ultrasound-guided Erector Spinae Plane Block for Postoperative Analgesia after Video-Assisted Thoracic Surgery: A Retrospective Study

“…However, some studies have pointed out that thoracic paravertebral block can easily cause epidural hematoma or spinal cord injury, and excessive use of drugs can greatly harm the respiratory movement, muscle strength, and circulatory system of patients. Furthermore, this mode has many contraindications, including the use of anticoagulants, coagulopathy, or hemodynamic instability, thereby ultimately limiting its clinical application [14,15]. Ultrasound-guided erector spinae plane block can monitor the position and depth of the puncture needle in real time through ultrasound.…”

Loco-Regional Anesthesia for Pain Management in Robotic Thoracic Surgery

“…In fact, TEA can be particularly effective for managing the pain associated with port site incisions and the dissection of the thymus gland. Moreover, Kusano et al [ 24 ] performed a retrospective study comparing the effect of general anesthesia alone, general anesthesia combined with TEA, or general anesthesia combined with ultrasound-guided thoracic blocks. Their results showed that TEA provided better analgesia after robot-assisted thoracic surgery for mediastinal disease than general anesthesia alone, as indicated by lower pain scores and fewer rescue analgesic requirements.…”

Pain management after robot-assisted thoracic surgery for mediastinal disease: a first step towards randomized control trials

“…The authors demonstrated a statically significant difference in pain scores at six and twelve hours after surgery between the NB and TEA groups, in favor of TEA (numerical rating scale 1.2±1.6 vs. 2.4±1.8 and 1.2±1.5 vs. 2.2±1.7). This finding is important but as highlighted by the authors, the clinical impact of this small difference may be questioned ( 2 ). Indeed, a statistical significance does not necessarily mean that the effect is clinically relevant.…”

“…Postoperative pain after robot-assisted thoracic surgery (RATS) for mediastinal disease alone has not been addressed to this day. Having investigated pain after RATS for both lung resection and mediastinal disease ( 1 ), Kusano et al focused this time more specifically on mediastinal surgery ( 2 ). It is particularly helpful to be able to rely on the results of procedure-specific studies.…”

“…In their retrospective study including 169 patients with mediastinal disease, Kusano et al compared postoperative pain as well as adverse effects in the first 48 hours in three groups of patients: no block (NB), thoracic epidural analgesia (TEA), and ultrasound-guided thoracic paraspinal block (TB) ( 2 ).…”