Analgesic management after thoracoscopic surgery: recent studies and our experience

Abstract

Thoracoscopic surgery (TS) is a less invasive procedure t h a n o p e n t h o r a c o t o m y b e c a u s e i t i n v o l v e s l e s s postoperative pain, a lower complication rate, a shorter time to ambulation, and shorter hospitalization. Clinically, patients who undergo TS do not always harbor mild-tomoderate postoperative pain. Additionally, the insufficient management of postoperative pain might lead to the development of chronic pain. We previously reported that individual pain scores after TS are classified as no and mild (0-3/10), moderate (4-6/10), and severe (7-10/10) using the numerous rating scale (NRS). In an analysis of 524 patients who underwent TS, the incidence of mild pain was 87.0% on the operative day and 75.6% during ambulation (1). The mean NRS score after TS in patients who received a single-shot intercostal nerve block (INB) using ropivacaine was 1.83±1.49 on the operative day, 2.73±1.75 during ambulation, and 1.87±1.33 during settling, after receiving several analgesic drugs after TS, whereas the mean NRS score was 3.05±1.51 during ambulation after open thoracotomy in patients who received paravertebral block (PVB) or epidural analgesia (EA); thus, pain scores were significantly higher after open thoracotomy than TS (P<0.01) (1).However, there is still no consensus regarding optimal pain management after TS. In the present editorial, we focus on clinical acute post-thoracoscopic pain (APTP) and chronic post-thoracoscopic pain (CPTP) management after TS with reference to recent studies and our experience. APTP APTP after TS, including neuropathic pain, is likely a type of nociceptive pain that occurs from tissue trauma. Nociceptive pain occurs when thoracic tissues, such as intercostal muscles, pleura, ribs, and intercostal nerves, are impaired, and the continuous stimulus is perceived as painful. In our previous data, 13.0% and 24.4% of patients experienced moderate or severe pain on the operative day and during ambulation, respectively, and those patients with pain had a higher probability of requiring plural analgesics (1). Kaplowitz et al. determined that acute control is important for the following two reasons: to prevent splinting and stretching of the surgical incisions as a result of breathing and to help provide effective pre-emptive analgesia (2). Regional analgesia (EA/PVB/INB/multimodal analgesic regimen)EA EA is the gold standard for thoracotomy. In 312 patients who underwent pneumonectomy at the 24 United Kingdom thoracic surgical centers in 2005, the most common type of analgesia used was epidural (61.1%), followed by paravertebral infusion (31%) (3). Despite being the most common analgesia after thoracic surgery, its frequent side effects, including urinary retention (42%), nausea (22%), itching (22%), and hypotension as a result of decreased Editorial

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“…Reduction of pain-related postoperative complications and speedy recovery are indispensable for ERAS implementation 20. In a previous study, we reported that the incidence of mild pain was 75.6% on post-TS ambulation, and we managed acute postthoracoscopic pain with intraoperative use of a single-shot ICB and postoperative use of tramadol 9,21. Wurnig et al, reported that compared to thoracic epidural anesthesia and a paravertebral block, an ICB seems to offer poorer pain control, yet it is favored for its lower incidence of adverse events 22.…”