Early Versus Late Paravertebral Block for Analgesia in Video-Assisted Thoracoscopic Lung Resection. A Double-Blind, Randomized, Placebo-Controlled Trial.

OBJECTIVES: Paravertebral local analgesia is effective in providing pain relief after video assisted thoracoscopic surgery. This randomized, double-blind pilot clinical trial investigated the effect of early perioperative delivery of paravertebral local analgesia to reduce postoperative pain after video assisted thoracoscopic lung resection and the feasibility of a larger trial. DESIGN: Double-blind, randomized, placebo-controlled trial. SETTING: University hospital, single institution. PARTICIPANTS: Patients over 18 years of age having video assisted lung resection surgery. INTERVENTIONS: 90 patients undergoing video assisted lung resection were randomized to receive bupivacaine via paravertebral catheter either before lung resection (early; n = 47) or at the end of the operation (late; n = 43). The primary outcome measure was pain on coughing during the first 24 postoperative hours. The 95% confidence interval for a median difference was calculated using the Hodges-Lehman median difference method. MEASUREMENTS AND MAIN RESULTS: There was no difference in pain scores between groups over the first 24 postoperative hours. The median (range) morphine equivalent consumption after 24 hours was 34 (7.3-105) mg with early paravertebral bupivacaine and 40.7 (3-91) mg after late paravertebral bupivacaine. The prevalence of chronic pain at 12 months postoperatively was 8.7% with early paravertebral bupivacaine and 25.8% with late paravertebral bupivacaine; the difference was not statistically significant. CONCLUSIONS: The authors found no difference in acute postoperative pain, but the decrease in morphine consumption and prevalence of chronic pain with early paravertebral bupivacaine, although not statistically significant, may warrant further investigation with a larger trial.

Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS).

Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.

The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer.

OBJECTIVE: The adoption of Enhanced Recovery After Surgery programs in thoracic surgery is relatively recent with limited outcome data. This study aimed to determine the impact of an Enhanced Recovery After Surgery pathway on morbidity and length of stay in patients undergoing lung resection for primary lung cancer. METHODS: This prospective cohort study collected data on consecutive patients undergoing lung resection for primary lung cancer between April 2012 and June 2014 at a regional referral center in the United Kingdom. All patients followed a standardized, 15-element Enhanced Recovery After Surgery protocol. Key data fields included protocol compliance with individual elements, pathophysiology, and operative factors. Thirty-day morbidity was taken as the primary outcome measure and classified a priori according to the Clavien-Dindo system. Logistic regression models were devised to identify independent risk factors for morbidity and length of stay. RESULTS: A total of 422 consecutive patients underwent lung resection over a 2-year period, of whom 302 (71.6%) underwent video-assisted thoracoscopic surgery. Lobectomy was performed in 297 patients (70.4%). Complications were experienced by 159 patients (37.6%). The median length of stay was 5 days (range, 1-67), and 6 patients (1.4%) died within 30 days of surgery. There was a significant inverse relationship between protocol compliance and morbidity after adjustment for confounding factors (odds ratio, 0.72; 95% confidence interval, 0.57-0.91; P < .01). Age, lobectomy or pneumonectomy, more than 1 resection, and delayed mobilization were independent predictors of morbidity. Age, lack of preoperative carbohydrate drinks, planned high dependency unit/intensive therapy unit admission, delayed mobilization, and open approach were independent predictors of delayed discharge (length of stay >5 days). CONCLUSIONS: Increased compliance with an Enhanced Recovery After Surgery pathway is associated with improved clinical outcomes after resection for primary lung cancer. Several elements, including early mobilization, appear to be more influential than others.