Abstract
Background:
Uniportal thoracoscopic surgery has become widely accepted for its favourable outcomes with regard to pain. However, post-operative pain is still a concern associated with thoracic surgery. The objective of this study was to evaluate the post-operative pain of patients undergoing uniportal video-assisted thoracoscopic surgery (VATS) lobectomies using an intra-operative intercostal nerve block.
Methods:
All consecutive patients undergoing uniportal VATS lobectomies between October 2018 and October 2019 were reviewed retrospectively. Twenty consecutive patients in Group A underwent uniportal VATS lobectomies without intra-operative intercostal nerve blocks. The other 20 consecutive patients in Group B underwent uniportal VATS lobectomies with intra-operative intercostal nerve blocks. Numeric Pain Rating Scale (NRS) scores were recorded at 1, 12 and 24 h postoperatively. The number of anti-inflammatory drugs (non-steroidal anti-inflammatory drug [NSAIDs]) consumed until the time of chest tube removal was also recorded.
Results:
There was no difference between the groups with regard to sex, age, chest tube duration, length of stay, operative time or laterality. There was a significant difference in post-operative NRS scores at 1 h (P < 0.001) and 12 h (P = 0.014) between the groups. The NSAID consumption was significantly lower in Group B than in Group A (P = 0.038).
Conclusion:
Intra-operative intercostal nerve blocks with bupivacaine provided immediate post-operative pain relief and reduced post-operative opioid consumption in patients who underwent uniportal VATS lobectomies.
Keywords: Intercostal nerve block, lobectomy, uniport video-assisted thoracoscopic surgery
INTRODUCTION
In the field of thoracic surgery, video-assisted thoracoscopic surgery (VATS) has become the favoured approach since VATS has an advantage in alleviating post-operative pain compared to thoracotomy.[1] The VATS approach is recommended as the standard treatment method for clinical Stage I non-small-cell lung cancer by the American College of Chest Physicians[2] and the National Comprehensive Cancer Network.[3] Recently, a number of surgeons have demonstrated the feasibility of performing VATS through a single incision. In comparison with multiport VATS, uniportal VATS has demonstrated favourable outcomes.[4,5] Although uniportal VATS has become more widely accepted, post-operative pain remains the main concern.[6] Various methods, such as oral analgesic agents, intramuscular morphine injection, intercostal nerve blockade and epidural analgesia, have been used for the treatment of VATS post-operative pain. The advantage of using a thoracoscopic internal intercostal block was reported.[7] We hypothesise that the use of an intra-operative intercostal block would enhance pain control in patients undergoing uniportal VATS lobectomies.
METHODS
Patients
This retrospective study was approved by the Institutional Review Board of Haeundae Paik Hospital at the Inje University of Korea. The patients were divided into two groups. In Group A, 20 consecutive patients underwent elective uniportal VATS lobectomies without intra-operative intercostal nerve blocks between October 2018 and April 2019. In Group B, 20 consecutive patients underwent elective uniportal VATS lobectomies with intra-operative intercostal nerve blocks between June 2019 and October 2019. Patients with benign pulmonary disease and lung cancer requiring anatomical lung resection were included in the inclusion criteria of uniportal VATS lobectomy. The indication for uniportal VATS lobectomy for lung cancer included: (i) Clinical Stage I–II patients; (ii) clinical Stage IIIA patients with resectable N2 station metastasis. Patients who underwent surgery in the ipsilateral thorax were excluded from both groups because adhesion and prolongation of operative time could affect post-operative pain.
All patients used intravenous (IV) patient-controlled anaesthesia (PCA). The agent for PCA was made into 100 ml by mixing 2000 μg of fentanyl and normal saline. If the patient had additional analgesic requirements postoperatively, ibuprofen 800 mg was injected intravenously when the numeric pain rating scale (NRS) score (0 being no pain and 10 being the worst pain imaginable) was more than 6. During the post-operative period, the patient's pain level was assessed by NRS scores, which was the primary outcome of the study. The NRS scores were recorded at 1, 12 and 24 h postoperatively. The secondary outcomes were the number and amount of anti-inflammatory drugs (non-steroidal anti-inflammatory drug [NSAIDs]) consumed until the time to chest tube removal.
Surgical technique: Uniportal video-assisted thoracoscopic surgery
All patients were placed under double-lumen intubation anaesthesia on lateral decubitus position. In both groups, an incision measuring 4–5 cm was made in the fifth or sixth intercostal space on the anterior axillary line. The soft tissue and intercostal muscles were retracted with an X-small wound retractor (Alexis; Applied Medical, Rancho Santa Margarita, CA, USA) to secure the intercostal space. All procedures were performed with a 5-mm, 30° video thoracoscope, endoscope instruments, Ligasure™ (Valleylab, Covidien, Boulder, CO, USA), and an endoscopic linear stapler. At the end of the procedure, a chest tube (24 Fr.) was placed in the thoracic cavity. The chest tube was inserted through a single incision.
Intra-operative internal intercostal nerve block
At the end of VATS lobectomy, a 23G scalp needle was introduced through the uniport. According to the need, the scalp needle was bent about 30°. An injection of 5 cc of 0.5% bupivacaine HCl 0.5% was performed under the parietal pleura in the region of the intercostal bundle after careful aspiration. The location of the injection was from the third to the seventh intercostal space lateral to the sympathetic chain. Thoracoscope monitoring was conducted to detect a bulge in the parietal pleura and bleeding.
Statistical analysis
The continuous variables are presented as interquartile range or mean ± standard deviation to compare the continuous variables, the t-test for normally distributed data or the Mann–Whitney U-test for non-normally distributed data was used. The categorical variables are presented as numbers and percentages. To compare the categorical variables, the Chi-squared test or Fisher's exact test was used. The statistical analyses were conducted using SPSS (Version window 18.0; SPSS Inc., Chicago, IL, USA). For all analyses, statistical significance was set at P < 0.05.
RESULTS
A total of 40 patients undergoing lobectomy using uniportal VATS were included in this analysis. Twenty patients in Group B received intra-operative intercostal nerve blocks using 0.5% bupivacaine HCl 0.5% at the end of surgery. The 20 patients in Group A did not receive intra-operative intercostal nerve blocks. The patient demographics included sex, age, chest tube duration, length of stay, operative time, laterality time, diagnosis and pathologic stage. There were no significant differences between the groups [Table 1].
Table 1.
Patient characteristics
| Characteristics | Group A (n=20) | Group B (n=20) | P |
|---|---|---|---|
| Sex | |||
| Male, n (%) | 11 (55.0) | 13 (65.0) | 0.519 |
| Age (year) | 64.10 (59.00-73.50) | 62.75 (58.25-73.00) | 0.711 |
| Chest tube duration (h) | 131.60 (91.75-164.13) | 110.73 (54.38-159.00) | 0.178 |
| Length of stay (d) | 9.15 (7.00-11.00) | 8.15 (6.25-10.75) | 0.311 |
| Operative time (min, mean±SD) | 165.75±50.35 | 168.75±70.11 | 0.877 |
| Laterality | |||
| Left, n (%) | 9 (45.0) | 9 (45.0) | 0.624 |
| Diagnosis, n (%) | |||
| Adenocarcinoma | 10 (50.0) | 11 (55.0) | - |
| Squamous cell carcinoma | 3 (15.0) | 3 (15.0) | - |
| Metastasis | - | 2 (10.0) | - |
| Small-cell carcinoma | 3 (15.0) | - | - |
| Benign disease | 3 (15.0) | 2 (10.0) | - |
| Other | 1 (5.0) | 2 (10.0) | - |
| Pathologic stage, n (%) | |||
| IA1 | 1 (5.88) | 1 (6.67) | - |
| IA2 | 2 (17.96) | 1 (6.67) | - |
| IA3 | 1 (5.88) | 8 (53.33) | - |
| IB | 3 (17.65) | 1 (6.67) | |
| IIA | 1 (5.88) | 1 (6.67) | - |
| IIB | 5 (29.41) | 1 (6.67) | - |
| IIIA | 2 (11.76) | - | - |
| IIIB | 2 (11.76) | 2 (13.33) | - |
*Values in parentheses are IQR or percentage. IQR: Interquartile range
The postoperative NRS scores are shown in Table 2. There was a significant difference in postoperative NRS scores at 1 h and 12 h between the two groups. There was not a significant difference in post-operative NRS scores at 24 h. The number of post-operative analgesics injected until the time of chest tube removal is shown in Table 3. The NSAID consumption until the time of chest tube removal was significantly lower in Group B than in Group A.
Table 2.
Post-operative numeric pain rating scale scores
| Time after surgery | Group A (n=20) | Group B (n=20) | P |
|---|---|---|---|
| 1 h | 5.60±1.23 | 3.45±0.83 | <0.001 |
| 12 h | 4.70±1.53 | 3.50±1.43 | 0.014 |
| 24 h | 4.25±1.48 | 4.10±1.65 | 0.764 |
*Values are presented as mean±SD of numeric pain score.
SD: Standard deviation
Table 3.
Post-operative analgesic use
| Number of injections (mean±SD) | Group A (n=20) | Group B (n=20) | P |
|---|---|---|---|
| NSAID | 2.35±2.54 | 0.95±1.36 | 0.038 |
*Values are presented as mean±SD of injection number. SD: Standard deviation, NSAID: Non-steroidal anti-inflammatory drug, SD: Standard deviation
DISCUSSION
In the field of thoracic surgery, effective pain control can reduce post-operative pulmonary complications and relieve patient concerns. Despite the advantages over a thoracotomy with regard to pain, VATS can still induce significant post-operative pain and temporary impairment of lung function. Various efforts have been undertaken to alleviate VATS post-operative pain, including local analgesia, general IV analgesia, epidural blocks and intercostal nerve blocks.[7] Bolotin et al. reported the significant advantage of intercostal nerve blocks for pain management after thoracoscopic surgery.[8] The advantage of an intra-operative intercostal nerve block is the accuracy of the block. The injection of local anaesthetics is performed under direct vision, and a bulge in the visceral pleura can be seen over the intercostal space. Temes et al. reported a thoracoscopic nerve block supplying the intercostal spaces entered during the procedure.[9] However, local anaesthetic leakage through the damaged parietal pleura can occur. Hsieh et al. reported a continuous intercostal nerve block after uniportal VATS anatomical resection.[10] The intercostal catheter placement is a more invasive procedure and more expensive than simple intra-operative intercostal nerve blocks. In our study, the injection was done at multiple levels, from the third to the seventh intercostal space, to alleviate the pain caused by the uniport performed through the fifth intercostal space.
In 2004, Rocco first reported experience with uniportal VATS wedge resection.[4] Since then, this technique has been adopted by several centres in Europe and Asia. Beginning in 2011, our hospital adopted uniportal VATS and it is currently used as a standard means of minimally invasive thoracic surgery. To improve on the results of uniportal VATS, we thought that appropriate post-operative pain control would be very important. In our study, a decrease in immediate post-operative pain, which was assessed at 1 and 12 h post-operatively, was achieved by using an intra-operative intercostal nerve block. Furthermore, post-operative NSAID consumption until the time of chest tube removal was also decreased in the intra-operative intercostal nerve block group.
This study has several limitations. First, this study was a retrospective study based on a relatively small cohort from a single institution. To evaluate the efficacy of intra-operative intercostal nerve blocks in uniportal VATS, a larger multi-institutional, prospective study may be necessary. Second, our study only investigated the immediate post-operative period, so we could not recognise the development of chronic pain. To minimise potential bias in a retrospective study, all procedures were performed by a single surgeon.
In conclusion, an intra-operative intercostal nerve block with bupivacaine during a uniportal VATS lobectomy could alleviate immediate post-operative pain.
CONCLUSION
The results of our retrospective study showed that an intra-operative intercostal nerve block with bupivacaine provided immediate post-operative pain relief and reduced the post-operative opioid consumption in patients who underwent uniportal VATS lobectomies.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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