Serratus anterior plane block for hybrid transthoracic esophagectomy: a pilot study

Abstract

BackgroundPain is a major limiting factor in patient’s recovery from major thoracic surgical procedures. Thoracic epidural analgesia (TEA), the current gold standard of perioperative management, has contraindications, can technically fail, and carries a risk of complications such as epidural abscess and spinal hematoma. The ultrasound-guided serratus anterior plane (SAP) block is a promising regional analgesia technique.ObjectivesSince the anatomic space involved in the SAP block corresponds to the area exposed by the surgeon during right posterolateral thoracotomy, we investigated the feasibility of a “surgically guided” continuous SAP block as an alternative to TEA in selected esophagectomy patients.Study designThis was a pilot case-series study.SettingThis study was carried out in a tertiary-care university hospital.MethodsThe demographic and clinical data of patients in whom the continuous SAP block was performed were retrieved from a prospectively maintained database of hybrid (laparoscopy plus right thoracotomy) Ivor Lewis esophagectomy. The SAP block was performed upon closure of the thoracotomy incision using a 19-gauge catheter tunnelized subcutaneously and positioned in the deep plane between the serratus anterior muscle and the ribs. A bolus dose of 30 mL of levobupivacaine 0.25% was injected, followed by a continuous infusion of the 0.125% solution at 7 mL/h until postoperative day 4.ResultsBetween January 2016 and July 2016, seven (20%) out of 37 esophagectomy patients underwent a SAP block rather than TEA for the following reasons: inability to insert the epidural catheter, antiaggregation or anticoagulant therapy, or unplanned thoracotomy. The procedure was uneventful in all patients. Only two patients required rescue analgesia on day 1.ConclusionContinuous SAP block under direct vision is feasible and safe. This novel “surgically guided” application of the SAP block may be useful in case of failure or contraindications to TEA.

A randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery

“…Serratus anterior plane block did not affect the median (IQR [range]) time until chest tube removal or hospital discharge: 3 (2–4 [2–19]) days vs. 3 (3–5 ) days, p = 0.22; and 6 (5–6 [3–22]) days vs. 6 (5–7 [4–21]) days, p = 0.47, respectively. Postoperative respiratory complications were recorded for two patients, neither of whom had a block, one of whom died of pneumonia.…”

“…A few small studies have described the use of serratus anterior plane block for thoracic surgery , with analgesia similar to an epidural but perhaps with less haemodynamic instability . The serratus anterior block may be performed at superficial or deep planes .…”

The impact of ultrasound‐guided continuous serratus anterior plane block versus intravenous patient‐controlled analgesia on the incidence and severity of post‐thoracotomy pain syndrome: A randomized, controlled study

“…Regional analgesic techniques include thoracic epidural analgesia (TEA), which is considered by many as the gold standard analgesic technique for post-thoracotomy pain (Barbera, Milito, Punturieri, Asti, & Bonavina, 2017;Joshi et al, 2008). Other regional analgesic techniques include paravertebral analgesia (PVB), intercostal nerve blocks and intrapleural analgesia.…”

Rhomboid Intercostal and Subserratus Plane Block

“…The serratus anterior plane block 3,4 has been used for analgesia after breast surgery, [5][6][7][8] postmastectomy pain, 9,10 thoracoscopic surgery, 11,12 pain associated with rib fractures, shoulder surgery, [13][14][15][16] open thoracotomy, 17 and postthoracotomy pain. [18][19][20] The erector spinae plane block 21 has been used for acute postsurgical pain, posttraumatic pain 21,22 and chronic neuropathic pain conditions. 21 We previously reported the extent of contrast spread in cadavers following the rhomboid intercostal block at one injection point in the triangle of auscultation.…”