Abstract
Background
Pulmonary lobectomy is the standard of care for the treatment of early-stage non-small cell lung cancer. This study investigated the rate of utilization of supplemental anesthesia in patients undergoing video-assisted thoracoscopic surgery (VATS) or open lobectomy using a national database and assessed the effect of regional block (RB) on postoperative outcomes.
Methods
Patients who underwent lobectomy for lung cancer between 2014–2019 were identified in the American College of Surgeons National Surgical Quality Improvement Program. The patients’ primary mode of anesthesia and supplemental anesthesia were recorded. Preoperative characteristics and postoperative outcomes were compared between 2 surgical groups those who underwent general anesthesia (GA) alone versus GA with RB. Multivariable regression analyses were performed on the outcomes of interest.
Results
In total, 13,578 patients met the study criteria, with 87% undergoing GA and the remaining 13% receiving GA and RB. The use of neuraxial anesthesia decreased over the years, while RB use increased up to 20% in 2019. Age, body mass index, and preoperative comorbidities were comparable between groups. Patients who underwent VATS were more likely to receive RB than those who underwent thoracotomy. RB was most often utilized by thoracic surgeons. An adjusted analysis showed that RB use was associated with shorter hospital stays and a reduced likelihood of prolonged length of stay, but a higher rate of surgical site infections (SSIs).
Conclusion
In a large surgical database, there was underutilization of supplemental anesthesia in patients undergoing lobectomy for lung cancer. RB utilization was associated with a shorter length of hospital stay and an increase in SSI incidence.
Keywords: Lobectomy, Anesthesia, National Surgical Quality Improvement Program, Outcomes
Introduction
Lung cancer is the leading cause of cancer-related deaths worldwide [1]. Survival in lung cancer continues to be among the lowest when compared to other cancers [2]. Approximately 80%–85% of all newly diagnosed lung cancers are non-small cell lung cancer (NSCLC) [3]. For early-stage NSCLC, lobectomy performed by thoracotomy or minimally invasive thoracoscopic or robotic-assisted surgery is the standard of care for oncological resection [4,5]. Thoracic surgery poses unique challenges in the anesthetic management and pain control of these patients. General anesthesia (GA) is the standard of care in the operative management of patients undergoing lobectomy, with supplemental anesthesia—including neuraxial (spinal or epidural) or regional block (RB)—being an important adjunct.
Supplemental anesthesia plays a significant role in optimizing postoperative pain management [6]. RB, including paravertebral, serratus anterior, and intercostal nerve blocks, has been proposed for pain control in patients undergoing lobectomy [7]. Some studies have reported similar analgesic efficacy for RB compared to neuraxial anesthesia in patients undergoing thoracotomy, with a better safety profile [8].
The available data on the use of regional anesthesia in lung cancer resection patients mostly come from single-institution studies with small numbers of patients [9-11]. There is a lack in the literature of a multicenter study assessing data on contemporary practice patterns of supplemental anesthesia use in patients undergoing video-assisted thoracoscopic surgery (VATS) or open lobectomy for lung cancer and evaluating the impact of RB on postoperative complications and outcomes. Using a large national surgical database, we aimed to investigate trends in the utilization of supplemental anesthesia and to assess the postoperative outcomes of patients undergoing lobectomy for early-stage NSCLC under GA alone versus GA with RB.
Methods
Due to its use of completely de-identified data, our study was deemed exempt by Virginia Commonwealth University Review Board. The requirement for informed consent from individual patients was omitted because of the retrospective design of this study.
Database and patient population
The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent lobectomy for lung cancer between 2014 and 2019. The ACS-NSQIP contains over 135 variables captured from de-identified surgical cases performed at participating hospitals. These variables include preoperative characteristics, intraoperative events, and postoperative outcomes within 30 days of the operation.
The Current Procedural Terminology codes 32663 and 32480 were used to identify patients who underwent lobectomy with the video-assisted thoracoscopic or open (thoracotomy) approach, respectively. Only patients with the following International Classification of Diseases (ICD), ninth revision codes for lung tumors were included: 162, 162.3, 162.4, 162.5, 162.8, and 162.9 for malignant neoplasms of the bronchus or lung; 209.7 for neuroendocrine tumors, 212.3 for benign neoplasms of bronchus and lung; 231.2 for carcinoma in situ; 235.7 for neoplasms of uncertain behavior of trachea, bronchus, and lung; and 239.1 for neoplasms of unspecified nature of the respiratory system. The ICD-10 codes included were C34 for malignant neoplasms of the bronchus and the lung, D02.21 and D02.22 for carcinoma in situ, D14.30 for benign neoplasms, D38.1 for neoplasms of uncertain behavior, D3A.090 for carcinoid tumors, D49.1 for other neoplasms of unspecified behavior of the respiratory system, and R91.1 for solitary pulmonary nodules.
Patients with metastatic disease, an American Society of Anesthesiologists Physical Status Classification (ASA) class of 5, and cases of surgery performed in emergent settings were excluded from the study. Patients who underwent lobectomy for other pathologies, including infectious diseases (pulmonary abscess, mycobacterial infection, coccidioidomycosis, and mycoses) were not included given the technical difficulties and heterogenicity of outcomes in these cases.
Patient demographics and clinical characteristics, and study outcomes
The patients’ primary mode of anesthesia, as well as supplemental anesthesia (reported as other anesthetics in the NSQIP database), were recorded to assess the rate of utilization of regional anesthesia, including blocks and neuraxial (epidural and spinal) anesthesia, over the years. The patients were divided into 2 groups: those who underwent GA as a sole modality and those who underwent GA and RB. Patients who received GA and neuraxial anesthesia, as well as RB, were excluded.
The following preoperative variables were studied: demographic and anthropomorphic information (age, sex, and body mass index [BMI]), ASA class, history of weight loss greater than 10%, smoking (within the last year), and history of comorbid conditions (diabetes mellitus, hypertension, severe chronic obstructive pulmonary disease [COPD], congestive heart failure and chronic renal failure requiring dialysis). Severe COPD is defined by the NSQIP as a patient with a current diagnosis of COPD and functional disability from his/her disease, who requires chronic treatment or has had a recent hospitalization secondary to exacerbation [12].
The primary surgeon’s specialty (thoracic surgery, general surgery, or others [including cardiac surgery]) were compared. Postoperative adverse outcomes included pneumonia, pulmonary embolism, prolonged intubation (>48 hours), unplanned re-intubation, wound infection, urinary tract infection, acute renal failure, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, bleeding requiring transfusion, deep venous thrombosis, stroke, sepsis, length of stay as a numerical variable (truncated to the nearest day), prolonged hospital stay (>6 days) and 30-day mortality. Other postoperative outcomes included the rates of discharge to a facility, reoperation, and readmission.
Statistical analyses
Continuous variables were presented as mean±standard deviation or median and interquartile range and compared between the 2 surgical groups using 1-way analysis of variance or the Kruskal-Wallis test, whereas categorical variables were summarized via frequency and percentage and compared using the Pearson chi-square test or the Fisher exact test. For an adjusted analysis, multivariable linear or logistic regression models with a backward selection procedure via the Akaike information criterion were constructed for all postoperative outcomes of interest. The covariates considered in the model building process were preoperative demographics, comorbidities, the surgical approach, and the surgeon’s specialty. Odds ratios (ORs) along with 95% confidence intervals (CIs) were computed for each of the estimated parameters in the model. Due to the heavy right-skewness and overdispersion in the distribution of length of hospital stay, a log-transformation was applied to the outcome before constructing the linear regression model. IBM SPSS for Windows ver. 27.0 (IBM Corp., Armonk, NY, USA) and SAS ver. 9.4 (SAS Institute Inc., Cary, NC, USA) were used for all analyses, and a p-value <0.05 was considered to indicate statistical significance.
Results
An analysis of the use of supplemental anesthetics for open and VATS lobectomy for lung cancer from 2014–2019 demonstrated that the majority (74%) of lobectomies during this period were performed using GA alone, whereas GA and RB were performed in 13% of procedures. GA was performed with epidural anesthesia in 11% of procedures, spinal anesthesia in 1%, and both neuraxial anesthesia and RB in 1%. The percentages of utilization of supplemental anesthesia are illustrated in Fig. 1. The use of neuraxial anesthesia decreased over the years, while RB use increased to 20% of the patients in 2019 (Fig. 2).
Fig. 1.
The percentage of supplemental anesthesia utilization in patients undergoing lobectomy for lung cancer, 2014–2019. GA, general anesthesia.
Fig. 2.
Trends in the utilization of neuraxial and regional block.
A total of 13,578 patients met the inclusion and exclusion criteria for the study, with 87% undergoing GA and the remaining 13% receiving GA and RB. Age and BMI were comparable between both groups, with a mean age of 67 years and a mean BMI of 28 kg/m2. The GA-only group had a higher proportion of male patients than the GA with RB group. The proportions of patients with preoperative comorbidities such as diabetes mellitus, hypertension, congestive heart failure, end-stage renal disease on dialysis, and severe COPD were comparable between the groups. The patients who underwent VATS were more likely to receive RA than those who underwent thoracotomy (14.1% versus 10.4%, p<0.01). GA and RB were most often utilized by board-certified thoracic surgeons (96.6% versus 89.6%, p<0.01), while a higher percentage of board-certified general surgeons performed lobectomy under GA only (7.85% versus 2.20%, p<0.01) (Table 1).
Table 1.
Comparisons of demographics and preoperative clinical characteristics between the surgical groups
| Characteristic | Total | General anesthesia | General anesthesia+regional block | p-value |
|---|---|---|---|---|
| No. of patients | 13,578 (100.00) | 11,808 (87.00) | 1,770 (13.00) | |
| Age (yr) | 67.50±9.35 | 67.56±9.37 | 67.64±9.50 | 0.743 |
| Male sex | 5,967 (43.95) | 5,234 (44.33) | 733 (41.41) | 0.022 |
| Body mass index (kg/m2) | 28.03±6.00 | 28.01±6.04 | 27.92±5.79 | 0.567 |
| Weight loss >10% | 257 (1.89) | 227 (1.92) | 30 (1.69) | 0.513 |
| Diabetes mellitus | 2,301 (16.95) | 2,007 (17.00) | 294 (16.61) | 0.690 |
| Smoking | 4,820 (35.50) | 4,221 (35.75) | 599 (33.84) | 0.118 |
| Severe COPD | 3,273 (24.11) | 2,817 (23.86) | 456 (25.76) | 0.080 |
| Congestive heart failure | 72 (0.53) | 65 (0.55) | 7 (0.40) | 0.402 |
| Hypertension | 8,151 (60.03) | 7,083 (60.00) | 1,068 (60.34) | 0.777 |
| ESRD on dialysis | 46 (0.34) | 37 (0.31) | 9 (0.51) | 0.188 |
| ASA class | 0.398 | |||
| 1 & 2 | 2,438 (17.97) | 2,133 (18.08) | 305 (17.25) | |
| 3 & 4 | 11,128 (82.03) | 9,665 (81.92) | 1,463 (82.75) | |
| Lobectomy | <0.001 | |||
| VATS | 9,532 (70.20) | 8,184 (69.31) | 1,348 (76.16) | |
| Thoracotomy | 4,046 (29.80) | 3,624 (30.69) | 422 (23.84) | |
| Surgeon’s specialty | <0.001 | |||
| Thoracic surgery | 12,332 (90.82) | 10,622 (89.96) | 1,710 (96.61) | |
| General surgery | 966 (7.11) | 927 (7.85) | 39 (2.20) | |
| Others | 280 (2.06) | 259 (2.19) | 21 (1.19) |
Values are presented as number (%) for categorical variables or mean±standard deviation for continuous variables. The bold type is considered statistically significant.
COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease; ASA, American Society of Anesthesiologists; VATS, video-assisted thoracoscopic surgery.
A baseline comparison of adverse perioperative outcomes showed comparable rates of pneumonia, sepsis, myocardial infarction, urinary tract infections, unplanned intubation, readmission, and mortality between the treatment groups. However, patients who underwent GA and RB had higher rates of surgical site infections (SSIs) (1.92% versus 1.00%, p<0.01), a longer total operative time (188.3±81.8 minutes versus 181.3±83.9 minutes, p<0.01), and a lower likelihood of a prolonged hospital stay (>6 days) (19.5% versus 23.2%, p<0.01). Patients in the GA and RB group had a shorter length of stay (4.89 days versus 5.21 days, p<0.01) (Table 2). The log-transformed length of stay was 1.67±0.53 in the GA group compared to 1.60±0.54 in the block patients (p<0.01).
Table 2.
Comparisons of adverse perioperative outcomes between surgical groups
| Variable | Total | General anesthesia | General anesthesia+regional block | p-value |
|---|---|---|---|---|
| No. of patients | 13,578 (100) | 11,808 (87) | 1,770 (13) | |
| Pneumonia | 637 (4.69) | 548 (4.64) | 89 (5.03) | 0.472 |
| Pulmonary embolism | 74 (0.54) | 64 (0.47) | 10 (0.07) | 0.903 |
| Prolonged intubation | 224 (1.65) | 192 (1.63) | 32 (1.81) | 0.573 |
| Unplanned intubation | 342 (2.52) | 298 (2.52) | 44 (2.49) | 0.925 |
| Superficial and deep SSI | 152 (1.12) | 118 (1.00) | 34 (1.92) | <0.001 |
| Organ space SSI | 87 (0.64) | 77 (0.65) | 10 (0.56) | 0.668 |
| Urinary tract infection | 161 (1.19) | 138 (1.17) | 23 (1.30) | 0.636 |
| Sepsis | 114 (0.84) | 98 (0.83) | 16 (0.90) | 0.750 |
| Cardiac arrest | 91 (0.67) | 80 (0.68) | 11 (0.62) | 0.788 |
| Myocardial infarction | 87 (0.64) | 75 (0.64) | 12 (0.68) | 0.833 |
| CVA with neurological deficit | 70 (0.52) | 61 (0.52) | 9 (0.51) | 0.965 |
| Acute renal failure | 46 (0.34) | 39 (0.33) | 7 (0.40) | 0.660 |
| Bleeding requiring transfusion | 490 (3.61) | 437 (3.70) | 53 (2.99) | 0.137 |
| DVT/thrombophlebitis | 76 (0.56) | 63 (0.53) | 13 (0.73) | 0.291 |
| Total operative time (min) | 183.19±84.04 | 181.30±83.89 | 188.25±81.83 | 0.001 |
| Length of hospital stay (day) | 5.27±4.35 | 5.21±4.36 | 4.89±4.58 | <0.001 |
| Length of hospital stay (day) | 4.00 (3.00–6.00) | 4.00 (3.00–6.00) | 4.00 (2.00–6.00) | <0.001 |
| Prolonged hospital stay (>6 day) | 3,089 (22.75) | 2,744 (23.24) | 345 (19.49) | <0.001 |
| Length of stay >30 day | 37 (0.27) | 32 (0.27) | 5 (0.28) | 0.931 |
| Mortality | 157 (1.16) | 141 (1.19) | 16 (0.90) | 0.287 |
| Any complication | 1,680 (12.37) | 1,453 (12.31) | 227 (12.82) | 0.535 |
| Discharge to a facility | 682 (5.03) | 606 (5.14) | 76 (4.30) | 0.217 |
| Reoperation | 552 (4.07) | 468 (3.96) | 84 (4.75) | 0.120 |
| Readmission | 1,003 (7.41) | 876 (7.44) | 127 (7.20) | 0.720 |
Values are presented as number (%) for categorical variables, mean±standard deviation for continuous variables, or median (25th–75th percentile interquartile range), unless otherwise stated. The bold type is considered statistically significant.
SSI, surgical site infection; CVA, cerebrovascular accident; DVT, deep venous thrombosis.
Adjusted analyses of the impact of RB supplementation on postoperative outcomes demonstrated that patients with GA and RB had higher odds of SSI (OR, 1.97; 95% CI, 1.34–2.90) and a longer operative time (OR, 7.82; 95% CI, 3.68–11.97), but lower odds of a prolonged (>6 days) hospital stay (OR, 0.86; 95% CI, 0.76–0.99) (Table 3). RB did not impact the rates of other postoperative complications.
Table 3.
Adjusted analysis of the associations of regional anesthesia associations with post-lobectomy outcomes
| Outcome | Associations of regional anesthesia with outcomes | |
|---|---|---|
|
| ||
| OR (95% CI) | p-value | |
| Pneumonia | 1.16 (0.92–1.47) | 0.211 |
| Pulmonary embolism | 1.04 (0.53–2.03) | 0.914 |
| Prolonged intubation | 1.19 (0.81–1.75) | 0.371 |
| Unplanned intubation | 1.04 (0.75–1.44) | 0.814 |
| Superficial and deep SSI | 1.97 (1.34–2.90) | 0.001 |
| Organ space SSI | 0.89 (0.46–1.73) | 0.736 |
| Urinary tract infection | 1.10 (0.71–1.73) | 0.664 |
| Sepsis | 1.11 (0.65–1.90) | 0.690 |
| Cardiac arrest | 0.99 (0.53–1.09) | 0.980 |
| Myocardial infarction | 1.07 (0.58–1.98) | 0.824 |
| CVA with neurological deficit | 1.00 (0.50–2.03) | 0.995 |
| Acute renal failure | 1.36 (0.61–3.08) | 0.454 |
| Bleeding requiring transfusion | 0.90 (0.67–1.20) | 0.487 |
| DVT/thrombophlebitis | 1.46 (0.80–2.67) | 0.219 |
| Total operative time (min) | 7.82 (3.68–11.97) | <0.001 |
| Prolonged hospital stay (>6 day) | 0.86 (0.76–0.99) | 0.030 |
| Length of stay >30 day | 1.10 (0.42–2.86) | 0.844 |
| Mortality | 0.78 (0.46–1.32) | 0.355 |
| Any complication | 1.12 (0.96–1.30) | 0.156 |
| Discharge to a facility | 0.87 (0.69–1.14) | 0.344 |
| Reoperation | 1.25 (0.98–1.59) | 0.069 |
| Readmission | 0.99 (0.82–1.20) | 0.926 |
The bold type is considered statistically significant.
OR, odds ratio; CI, confidence interval; SSI, surgical site infection; CVA, cerebrovascular accident; DVT, deep venous thrombosis.
The predictors of length of hospital stay are delineated in Table 4. Adjusted for preoperative and demographic characteristics, the use of RB was associated with a 4.2% reduction in length of stay (p=0.001). Conversely, patients with COPD had an estimated effect of a 19% increase in length of hospital stay. The results of this analysis demonstrate that age, BMI, male sex, preoperative weight loss, smoking, hypertension requiring medication, dialysis, ASA class, and surgical specialty were also significant predictors of the length of stay.
Table 4.
Predictors associated with the length of hospital stay after lobectomy for lung cancer
| Associated factor | Predictors associated with the length of hospital stay | |
|---|---|---|
|
| ||
| Coefficient (95% CI) | p-value | |
| Addition of regional anesthesia | 0.96 (0.93–0.98) | 0.001 |
| Age | 1.005 (1.004–1.006) | <0.001 |
| Sex (male vs. female) | 1.05 (1.03–1.07) | <0.001 |
| Body mass index | 0.996 (0.994–0.997) | <0.001 |
| Preoperative weight loss >10% | 1.10 (1.03–1.17) | 0.003 |
| Smoking | 1.09 (1.07–1.12) | <0.001 |
| Chronic obstructive pulmonary disease | 1.19 (1.17–1.22) | <0.001 |
| Hypertension requiring medication | 1.03 (1.01–1.05) | 0.003 |
| Dialysis | 1.34 (1.16–1.55) | <0.001 |
| ASA 3/4 vs. 1/2 | 1.09 (1.07–1.12) | <0.001 |
| Thoracoscopic vs. open | 0.71 (0.70–0.72) | <0.001 |
| Surgeon’s specialty | <0.001 | |
| Thoracic vs. general | 0.98 (0.95–1.01) | 0.144 |
| Other vs. thoracic | 1.18 (1.10–1.25) | <0.001 |
The bold type is considered statistically significant.
CI, confidence interval; ASA, American Society of Anesthesiologists.
Discussion
Our study, using the NSQIP database, demonstrated an increased use of regional analgesia from 2014 to 2019. Despite an increase in the utilization of this anesthetic technique, only 13% of all lobectomy cases used RB throughout the study period. The gold standard for locoregional anesthesia for VATS and open lobectomy has previously been thoracic epidural analgesia [13,14]. A recent study has suggested the importance and efficacy of incorporating regional anesthesia into Enhanced Recovery After Surgery protocols in thoracic surgery patients [15]. With the increase in the use of regional analgesia in VATS and open thoracotomy cases, there is a need for contemporary research evaluating its effect on postoperative outcomes.
Our investigation found that, over time, more thoracic surgeons used RB during lobectomy for lung cancer. RB was more frequently used in VATS cases than in open thoracotomies. These 2 findings could potentially be related to each other. Thoracic surgeons’ increasing experience and comfort in performing thoracoscopic surgery and their familiarity with postoperative care for these patients may encourage surgeons to use RB, including performing intercostal blocks, during VATS. The increased rate of utilization of RB is supported by evidence from other studies demonstrating equal efficacy to neuraxial anesthesia (specifically, thoracic epidurals) with fewer complications [8].
Our study also found a significant decrease in prolonged hospitalizations when supplemental RB use was implemented, with similar overall complication rates. Among other factors, the surgical approach could contribute to prolonged hospitalization after lobectomy, as the VATS approach has been shown in previous studies to shorten the length of stay [16-18]. The use of RB in our analysis, after adjusting for other contributing factors including the surgical approach, was independently associated with a lower rate of prolonged length of stay. This finding could have been driven by better pain control and fewer sedative effects from narcotics; this would allow allowing patients to be more active and participate in pulmonary hygiene exercises following surgery, which would then lead to faster normalization to day-to-day activities and eventual early discharge [19].
Surgical trauma can lead to an increased surgical stress response, which can have an impact on the immune response because nociceptive receptors communicate with the brain and affect levels of proinflammatory cytokines and lymphocyte activity [20-22]. By providing improved analgesia, it would be reasonable to think that the level of immunosuppression following lobectomy would be reduced, leading to a lower risk of SSIs; this would be particularly reasonable to expect in patients undergoing VATS, which has lower rates of SSIs [23]. Our study found that patients receiving RB had higher rates of superficial and deep SSIs, which are typically managed with local drainage and antibiotics; however, the rates of sepsis and organ space infections were similar. This could potentially have been due to the introduction of extrinsic sources of infection via the migration of skin bacteria through a needle track site into the tissue surrounding the pleural cavity. These SSIs related to RB may result in potentially long-term adverse effects [24]. Although rare, the use of catheters during regional anesthesia could have introduced bacteria around the surgical site, leading to the increase in superficial and deep SSIs observed in our study [25]. This finding warrants further research and could potentially be an area for further improvement with the use of RB in thoracic surgery.
Lastly, our study evaluated various preoperative patient characteristics that had significant associations with length of stay. Age, male sex, preoperative weight loss, smoking history, history of COPD, hypertension requiring medication, dialysis dependency, and having a higher ASA score preoperatively are all correlated with an increased length of hospital stay following thoracic surgery. A focus on preventative medicine prior to surgery could reduce the length of stay for these patients following surgery. Smoking cessation education and the preoperative inclusion of registered dieticians for nutritional education can help to reduce comorbidities related to an increased length of stay, which can further reduce medical costs for the patients. The use of RB, the VATS approach, and surgery performed by a thoracic surgeon were all associated with a significantly shorter length of stay following lobectomy for lung cancer. Gaining more experience with focused postoperative management may help thoracic surgeons feel more comfortable discharging patients earlier after lobectomy.
This study has multiple limitations, most of which are inherent to the NSQIP database and the available variables. The NSQIP database is not specifically a thoracic surgery database; thus, it does not contain many perioperative factors that are important to this specialty, including preoperative pulmonary function tests, chest tube placement and duration, postoperative pain scores at various intervals, the extent of lymph node dissection, postoperative air leak, and tumor location. Many of these variables could have influenced the length of stay and complication rates, thus confounding the results of our study. The NSQIP database also does not go into detail regarding the type of block or the placement of catheters for RB versus a 1-time dose of anesthetic. Despite these limitations, we decided to use the NSQIP database, since it is a large national database that contains information from over 690 hospitals throughout the United States. This database is also risk-adjusted and case-mix-adjusted to account for differences between hospitals. These qualities made the NSQIP database desirable for answering our question regarding the impact of RB use on postoperative outcomes.
In conclusion, although there was an increasing trend in the use of RB in recent years, a large proportion of surgeons still solely utilized GA without the use of supplemental anesthesia. RB was used more frequently by thoracic surgeons and was independently associated with a shorter length of hospital stay and a lower likelihood of a prolonged hospital stay, but an increase in SSIs. RB did not affect other surgical complications, including pneumonia, organ space infection, sepsis, re-intubation, return to the operating room, and readmission.
Footnotes
Conflict of interest
No potential conflict of interest relevant to this article was reported.
References
- 1.Fitzmaurice C, Dicker D, et al. Global Burden of Disease Cancer Collaboration, author. The global burden of cancer 2013. JAMA Oncol. 2015;1:505–27. doi: 10.1001/jamaoncol.2015.0735. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin. 2019;69:7–34. doi: 10.3322/caac.21551. [DOI] [PubMed] [Google Scholar]
- 3.Youlden DR, Cramb SM, Baade PD. The International Epidemiology of Lung Cancer: geographical distribution and secular trends. J Thorac Oncol. 2008;3:819–31. doi: 10.1097/JTO.0b013e31818020eb. [DOI] [PubMed] [Google Scholar]
- 4.Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e278S–e313S. doi: 10.1378/chest.12-2359. [DOI] [PubMed] [Google Scholar]
- 5.Cao C, Zhu ZH, Yan TD, et al. Video-assisted thoracic surgery versus open thoracotomy for non-small-cell lung cancer: a propensity score analysis based on a multi-institutional registry. Eur J Cardiothorac Surg. 2013;44:849–54. doi: 10.1093/ejcts/ezt406. [DOI] [PubMed] [Google Scholar]
- 6.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. doi: 10.1213/01.ane.0000333274.63501.ff. [DOI] [PubMed] [Google Scholar]
- 7.Umari M, Falini S, Segat M, et al. Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice. J Thorac Dis. 2018;10(Suppl 4):S542–54. doi: 10.21037/jtd.2017.12.83. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Baidya DK, Khanna P, Maitra S. Analgesic efficacy and safety of thoracic paravertebral and epidural analgesia for thoracic surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2014;18:626–35. doi: 10.1093/icvts/ivt551. [DOI] [PubMed] [Google Scholar]
- 9.Xia Z, Depypere L, Song Y, et al. Uniportal thoracoscopic wedge resection of lung nodules: paravertebral blocks are better than intercostal blocks. Surg Innov. 2020;27:358–65. doi: 10.1177/1553350620921753. [DOI] [PubMed] [Google Scholar]
- 10.Haager B, Schmid D, Eschbach J, Passlick B, Loop T. Regional versus systemic analgesia in video-assisted thoracoscopic lobectomy: a retrospective analysis. BMC Anesthesiol. 2019;19:183. doi: 10.1186/s12871-019-0851-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lee EK, Ahn HJ, Zo JI, Kim K, Jung DM, Park JH. Paravertebral block does not reduce cancer recurrence, but is related to higher overall survival in lung cancer surgery: a retrospective cohort study. Anesth Analg. 2017;125:1322–8. doi: 10.1213/ANE.0000000000002342. [DOI] [PubMed] [Google Scholar]
- 12.American College of Surgeons National Surgical Quality Improvement Program, author. User guide for the 2018 ACS NSQIP Participant Use Data File (PUF) American College of Surgeons; Chicago (IL): 2019. [Google Scholar]
- 13.Zejun N, Wei F, Lin L, He D, Haichen C. 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. doi: 10.1111/1759-7714.12820. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Ueda K, Hayashi M, Murakami J, Tanaka T, Utada K, Hamano K. Intercostal block vs. epidural analgesia in thoracoscopic lung cancer surgery: a randomized trial. Gen Thorac Cardiovasc Surg. 2020;68:254–60. doi: 10.1007/s11748-019-01197-1. [DOI] [PubMed] [Google Scholar]
- 15.Mancel L, Van Loon K, Lopez AM. Role of regional anesthesia in Enhanced Recovery After Surgery (ERAS) protocols. Curr Opin Anaesthesiol. 2021;34:616–25. doi: 10.1097/ACO.0000000000001048. [DOI] [PubMed] [Google Scholar]
- 16.Desai H, Natt B, Kim S, Bime C. Decreased in-hospital mortality after lobectomy using video-assisted thoracoscopic surgery compared with open thoracotomy. Ann Am Thorac Soc. 2017;14:262–6. doi: 10.1513/AnnalsATS.201606-429OC. [DOI] [PubMed] [Google Scholar]
- 17.Nachira D, Meacci E, Margaritora S, Ismail M. Level of evidence on long-term results after VATS lobectomy: state of the art. J Thorac Dis. 2019;11:2192–4. doi: 10.21037/jtd.2019.06.19. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Nwogu CE, D'Cunha J, Pang H, et al. VATS lobectomy has better perioperative outcomes than open lobectomy: CALGB 31001, an ancillary analysis of CALGB 140202 (Alliance) Ann Thorac Surg. 2015;99:399–405. doi: 10.1016/j.athoracsur.2014.09.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Smith LM, Cozowicz C, Uda Y, Memtsoudis SG, Barrington MJ. Neuraxial and combined neuraxial/general anesthesia compared to general anesthesia for major truncal and lower limb surgery: a systematic review and meta-analysis. Anesth Analg. 2017;125:1931–45. doi: 10.1213/ANE.0000000000002069. [DOI] [PubMed] [Google Scholar]
- 20.Novak-Jankovic V, Markovic-Bozic J. Regional anaesthesia in thoracic and abdominal surgery. Acta Clin Croat. 2019;58(Suppl 1):96–100. doi: 10.20471/acc.2019.58.s1.14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Beilin B, Shavit Y, Trabekin E, et al. The effects of postoperative pain management on immune response to surgery. Anesth Analg. 2003;97:822–7. doi: 10.1213/01.ANE.0000078586.82810.3B. [DOI] [PubMed] [Google Scholar]
- 22.Meiler SE. Long-term outcome after anesthesia and surgery: remarks on the biology of a newly emerging principle in perioperative care. Anesthesiol Clin. 2006;24:255–78. doi: 10.1016/j.atc.2006.03.002. [DOI] [PubMed] [Google Scholar]
- 23.Gordon M, Isenberg Y, Bain J. Unmasking hyperthyroidism in the elderly: how to distinguish hyperthyroidism from conditions that mimic the symptoms. Can Fam Physician. 1992;38:2397–404. [PMC free article] [PubMed] [Google Scholar]
- 24.Hebl JR, Niesen AD. Infectious complications of regional anesthesia. Curr Opin Anaesthesiol. 2011;24:573–80. doi: 10.1097/ACO.0b013e32834a9252. [DOI] [PubMed] [Google Scholar]
- 25.Schulz-Stubner S, Pottinger JM, Coffin SA, Herwaldt LA. Nosocomial infections and infection control in regional anesthesia. Acta Anaesthesiol Scand. 2008;52:1144–57. doi: 10.1111/j.1399-6576.2008.01712.x. [DOI] [PubMed] [Google Scholar]