Study reference

Study characteristics

Patient characteristics

Intervention (I) = PVB

Comparison / control (C) = TEB

Follow-up

Outcome measures and effect size

Comments

Method of insertion

Method of use

Method of insertion

Method of use

Yeung 2016

PS., study characteristics and results are extracted from the SR (unless stated otherwise)

SR and meta-analysis of  randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery

Literature search up to [month/year]

A: Bimston 1999

B: Cesati 2006

C: De Cosmo, 2002

D: Grider, 2012

E:  Gulbahar, 2020

F: Ibrahim, 2009

H: Kobayashi, 2013

I: Matthews, 1989

J: Messina 2009

M: Pintaric, 2011

N: Richardson, 1999

Study design: RCT

Setting and Country:

A: 2 hospitals, USA

B: single centre, Italy

C: single centre, Italy

D: single centre, USA

E: -, Turkey

F: single centre, Egypt

H: single centre, Japan

I: -, UK

J: single centre, Italy

M: single centre, Slovenia

N: single centre, UK

Source of funding and conflicts of interest:

Inclusion/exclusion criteria SR: 1) Types of studies: We included only randomized controlled trials (RCTs). We have excluded quasi-randomized trials, for example where allocation was determined by days of the week or hospital number. 2) Types of participants: We included all adults undergoing elective thoracotomy including for upper gastrointestinal surgery. 3) Types of interventions: We included continuous thoracic epidural infusions using local anaesthetics, opioids, and any adjuvant therapies. The comparator was continuous paravertebral blockade using local anaesthetics and adjuvant therapies.

11 studies included

Important patient characteristics at baseline:

Number of patients; characteristics important to the research question and/or for statistical adjustment (confounding in cohort studies); for example, age, sex, bmi, ...

N (I/C)

A: 30/20

B: 21/21

C: 25/25

D: 50/25

E: 25/19

F: 25/25

H: 35/35

I: 10/10

J: 12/12

M: 16/16

N: 46/54

Groups comparable at baseline?

A: Inserted under

direct vision by

surgeon

B: Percutaneously

by landmark

technique before

induction

of GA

C: Inserted under

direct vision by

surgeons

D: Inserted under

direct vision by

surgeon

E: Inserted under

direct vision by

surgeon

F: Percutaneously

by landmark

technique before

induction

of GA

H: Inserted under

direct vision by

surgeon

I: Percutaneously

by landmark at

the end of procedure

J: Percutaneously

by landmark

technique before

induction

of GA

M: Percutaneously

by landmark

technique before

induction

of GA

N: Inserted by surgeon

under direct

vision

A: 18 ml 0.5% bupivacaine

bolus

followed by infusion

of 0.1% bupivacaine with

10 `g/ml fentanyl,

10 - 15 ml/

hr

B: Pre-op Injections

by landmark

technique before

induction of GA

15 ml of 0.75%

ropivacaine

C: Used at the end

of operation only

D: Used at the end

of the operation

only

E: Used at the end

of operation only

F: 15 - 20 ml 0.5%

ropivacaine bolus

followed by

0.375% ropivacaine

0.1 ml/kg/

hr infusion

H: Used at the end

of operation only

I: Used at the end

of operation only

J: Used at the end

of operation only

M: 0.5% levopubivacaine

with 30

`g/kg morphine,

dose depends on

height

N: Pre-op Injections

by landmark

technique before

induction of GA

20 ml of 0.5%

bupivacaine

A: Percutaneously

by landmark technique

before induction

of GA

B: Percutaneously

by landmark technique

before induction

of GA

C: Percutaneously

by landmark technique

before induction

of GA

D: Percutaneously

by landmark technique

before induction

of GA

E: Percutaneously

by landmark technique

before induction

of GA

F: Percutaneously

by landmark technique

before induction

of GA

H: Percutaneously

by landmark technique

before induction

of GA

I: Percutaneously

by landmark technique

at the end of

procedure

J: Percutaneously

by landmark technique

before induction

of GA

M: Percutaneously

by landmark technique

before induction

of GA

N: Percutaneously

by landmark technique

before induction

of GA

A: Uncertain

whether

catheter was used during operation

B: 5 ml bolus of

0.75% ropivacaine

C: 5 ml bolus

of 0.2% ropivacaine

and

sufentanil

10 Zg given

as bolus.

Catheter used

during operation

if required

D: Used at the

end of operation

E: Used at the

end of operation

F: 5 - 8 ml of

0.5% ropivacaine

bolus

followed by

0.375% ropivacaine

0.1

ml/kg.hr infusion

H: Used at the

end of operation

I: Used at the

end of operation

J: Used at the

end of operation

M: 0.25% levopubivacaine

with

30 `g/kg morphine,

dose

depends on

height

N: 10 - 15 ml bolus

of 0.25%

bupivacaine

End-point of follow-up:

48 hours

For how many participants were no complete outcome data available?

(intervention/control)

There was no study reporting high levels of missing data (less

than 15% in all cases). However, we rated two studies at high risk

of bias: Gulbahar 2010 excluded 6/50 participants (12%), but all

from the epidural arm; Perttunen 1995 excluded 6/51 randomized

participants (12%).

Postoperative pain

Visual analogue scale scores (VAS) were used in all of the studies but the scales were different; a majority of studies used the 0 to 10 scale, but Kaiser 1998 used VAS in 0 to 4 categories (reported as mean and standard deviation (SD)), and two studies (Ibrahim 2009; Perttunen 1995) used VAS 0 to 5.

2-6h at rest

SMD [95% CI]:

C: 1.82 [1.16, 2.49]

D: -0.25 [-0.83, 0.34]

H: 0.10 [-0.37, 0.57]

I: 0.00 [-0.90, 0.90]

J: 0.37 [-0.44, 1.18]

M: -0.14 [-0.85, 0.56]

Pooled effect (random effects model): SMD 0.32, 95% CI -0.30 to 0.94

2-6h during coughing/ on movement

SMD [95% CI]:

C: 0.93 [0.34, 1.52]

D: 0.43 [-0.16, 1.02]

M: -0.20 [-0.90, 0.51]

Pooled effect (random effects model): SMD 0.41, 95% CI -0.20 to 1.03

24h at rest

SMD [95% CI]:

C: 0.39 [-0.17, 0.95]

D: 0.77 [0.16, 1.37]

H: -0.09 [-0.56, 0.38]

I: 0.08 [-0.82, 0.98]

J: 0.00 [-0.80, 0.80]

M: -0.32 [-1.03, 0.39]

Pooled effect (random effects model): SMD 0.16, 95% CI -0.17 to 0.48

24h during coughing/ on movement

SMD [95% CI]:

C: -0.05 [-0.61, 0.50]

D: -0.18 [-0.76, 0.41]

M: -0.61 [-1.33, 0.12]

Pooled effect (random effects model): SMD -0.23, 95% CI -0.58 to 0.12

Adverse events; hypotension

RR [95% CI]

A: 0.67 [0.04, 10.05]

B: 0.11 [0.01, 1.94]

D: 0.28 [0.02, 5.22]

E: 0.15 [0.01, 3.03]

F: 0.08 [0.00, 1.30]

H: 0.40 [0.08, 1.93]

I: 0.07 [0.00, 1.09]

N: 0.07 [0.00, 1.21]

Pooled effect (fixed effects model): RR 0.16, 95% CI 0.07 to 0.38

Aim: To compare the two regional techniques of TEB and PVB in adults

undergoing elective thoracotomy with respect to:

1. analgesic efficacy;

2. the incidence of major complications (including mortality);

3. the incidence of minor complications;

4. length of hospital stay;

5. cost effectiveness.

Study reference

Study characteristics

Patient characteristics ²

Intervention (I)

Comparison / control (C) ³

Follow-up

Outcome measures and effect size ⁴

Comments

PVB versus Epidural anesthesia - thoractomy

Huang, 2020

Type of study:

RCT

Setting and country: single centre, China

Funding and conflicts of interest: funding: This research was supported by Fujian Natural Science Foundation, China (No. 2018J01206). The journal’s Rapid Service Fee was funded by the authors. CI: Qiao-Wen Huang, Jia-Bin Li, Ye Huang, Wen-Qing Zhang and Zhi-Wei Lu have nothing to disclose

Inclusion criteria: elective unilateral thoracoscopic surgery for lung cancer (ASA II–III, aged less than 80 years old) from February 1, 2019 to October 31, 2019 in the Zhangzhou Affiliated Hospital of Fujian Medical University.

Exclusion criteria: all patients that had a history of thoracic spine surgery; coagulopathy; a BMI of 28 kg m-2 or higher; a history of drug allergies; ASA C IV; and patients that refused to participate in the trial

Surgery: thoracoscopic surgery for lung cancer

N total at baseline:

Intervention - T: 45

Intervention – P: 32

Control -E: 39

Important prognostic factors²:

For example

age ± SD:

I -T (n=50): 56.86 ± 10.31

I -P (n=50): 58.50 ± 9.61

C (n=48): 58.58 ± 9.68

Sex (M/F):

I I -T (n=50): 31/19

I -P (n=50): 23/27

C (n=48): 30/18

Groups comparable at baseline? There was no significant difference in the general characteristics of the three groups of patients

ultrasound-guided continuous thoracic paravertebral block

2 subgroups:

the interplanar approach in an oblique axial transverse section—T group;

0.33% of ropivacaine (AstraZeneca, imported drug registration no. H20140763, Lot NAZB) was injected at a dose of 1 mg kg-1

A dose of 0.7 mg kg-1 of 0.33% ropivacaine was added every 4 h during the operation

the interplanar approach in sagittal parasagittal section—P group

0.33% of ropivacaine (AstraZeneca, imported drug registration no. H20140763, Lot NAZB) was injected at a dose of 1 mg kg-1

A dose of 0.7 mg kg-1 of 0.33% ropivacaine was added every 4 h during the operation

continuous epidural analgesia (E-group)

injection of 0.25% of ropivacaine (3 ml) via the catheter. Another 3–5 ml was added every 5 min and the blocked segments by perceived less or lost sensation in response to cold and pinprick were tested until the blocked segments covered the surgical incision. The physician also recorded the plane stabilization time and the range of the blocking plane, and added 0.25% of ropivacaine 3–5 ml every 2 h during the operation.

Length of follow-up:

48h

After randomization (n=150, 50 patients in each group)

Loss-to-follow-up:

Intervention - T: 5

Reasons: haemorrhage (n=1); conversion of surgery approach (n=1); benign nodules (n=2); failure puncture (n=1)

Intervention – P: 18

Reasons: conversion of surgery approach (n=2); benign nodules (n=1); failure puncture (n=2); failure catheter placement (n=13)

Control -E: 11

Reasons: refuse (n=2); benign nodules (n=1); failure puncture (n=7);

Incomplete outcome data:

n.a.

Postoperative pain

numerical rating scale (NRS) scores at rest and during coughing at 2 h, 4 h, 8 h, 12 h, 24 h, 36 h, and 48 h after the surgery were recorded

Data per time-point reported in figure, not readable.

NRS ≥ 4 during 0–24 h post operation (n)

I -T: 38

I -P:  26

C : 27

NRS ≥ 4 during 24–48 h post operation (n)

I -T: 29

I -P: 23

C : 9

Opioid consumption

0–24 h opioids consumption (MME)

I -T: 8.75 ± 7.93

I -P: 8.98 ± 7.09

C : 2.24 ± 4.64

24–48 h opioids consumption (MME)

I -T: 10.28 ± 6.94

I -P: 9.38 ± 7.78

C : 1.60 ± 4.47

Study objective: to compare the challenge of puncture and catheterization and the effect of postoperative analgesia of ultrasound-guided continuous thoracic paravertebral block and the continuous epidural analgesia in patients receiving thoracoscopic surgery for lung cancer

Study conclusion: The continuous analgesia technique of paravertebral space catheterization cannot replace the continuous epidural analgesia in thoracoscopic lung cancer surgery as the latter technique is still considered to be the gold standard

Khoronenko, 2018

Type of study: RCT*

Setting and country: single centre, France

Funding and conflicts of interest: funding: The study was only supported by departmental funds. CI: All authors have no conflict of interest.

Inclusion criteria: adult patients and American Society of Anesthesiologists (ASA) physical status from I to III

Exclusion criteria: general anesthesia within 7 days before study inclusion, administration of an experimental drug within 30 days before surgery, preoperative pain syndrome, or use of analgesics, acute unstable angina, acute myocardial infarction documented by laboratory findings within the past 6 weeks, heart rate (HR) <50 beats per minute (bpm), systolic blood pressure (SBP) < 100 mmHg, heart block, and preoperative vasopressor administration.

Surgery: thoracotomy for non-small-cell lung cancer

N total at baseline:

I1: 100
C: 100

Important prognostic factors²:

For example

age ± SD:

I1: 58 ± 9
C: 55 ± 9

Sex (m/f):

I1: 77/23
Cl: 74/26

Groups comparable at baseline? The groups were comparable regarding demographic features, blood loss, and type and duration of surgery

I1: PVB

Propofol (2 mg/kg), fentanyl (0.002 mg/kg), ketamine (25 mg), and rocuronium (0.6 mg/kg) were administered for induction. After endotracheal intubation, anesthesia was maintained with sevoflurane (0.8–1 MAC), fentanyl (0.05–0.1 mg IV every 15–30 minutes when the SBP increased by more than 15% from the baseline value or was >140 mmHg).

TEA

Propofol (2 mg/kg), fentanyl (0.002 mg/kg), ketamine (25 mg), and rocuronium (0.6 mg/kg) were administered for induction. After endotracheal intubation, anesthesia was maintained with sevoflurane (0.8–1 MAC), fentanyl (0.05–0.1 mg IV every 15–30 minutes when the SBP increased by more than 15% from the baseline value or was >140 mmHg).

Length of follow-up:

6 months

Loss-to-follow-up (total)*:

Screened: 347 of whom 47 met exclusion criteria

Reasons: 17 patients suffered from an atrioventricular block I–II, 23 patients had a HR less than 50 bpm, and seven patients had preoperative hypotension with SBP less than 100 mmH.

Incomplete outcome data:

Not reported

Chronic pain

Horizontal VAS: 0 = no pain and 100 mm = worst possible pain. Static and dynamic pain components were assessed 7 days, 1 month, and 6 months after surgery

6 months – static (means ± standard deviation)

I1: 0.16 ± 0.39

C: 0.10 ± 0.30

6 months – dynamic (means ± standard deviation)

I1: 0.59 ± 0.98

C: 0.38 ± 0.79

*note that this is a study with 3 comparisons: PVB, INB and TEA

Stjudy objective: to assess whether the type of regional anesthesia influenced the incidence of chronic postthoracotomy pain syndrome (CPTPS).

Study conclusion: Patients who were administered TEA had less incidence and reduced intensity of CPTPS when compared with INB. Six months after surgery, the incidences of CPTPS were 23%, 34%, and 40% in the TEA, PVB, and INB groups, respectively. We did not find differences in CPTPS frequency and intensity between PVB and other groups. A pain syndrome that persists more than 1 month after surgery should be considered a predictor of pain syndrome chronicity.

Li, 2021

Type of study:

RCT

Setting and country: single-centre, China

Funding and conflicts of interest: funding: There was no external funding in the preparation of this manuscript. CI: h author certifies that he or she, or a member of his or her immediate family, has no commercial association (i.e., consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted manuscript.

Inclusion criteria: patients scheduled for elective thoracotomy

Exclusion criteria: contraindication to the use of TEA or TPVB, pregnancy, a history of cardiovascular and gastroesophageal surgery, preexisting pain syndrome, psychological disorders, coagulopathy, and severe hepatic, cardiovascular, or renal disorders. Standard posterolateral thoracotomy was chosen for all patients.

Surgery: elective thoracotomy

N total at baseline:

Intervention: 42

Control: 41

Important prognostic factors²:

For example

age ± SD:

I: 60.6 ± 9.0

C: 63.0 ± 9.6

Sex (ratio F/M)

I: 16/26

C: 9/32

Groups comparable at baseline? Yes, the 2 groups of patients were comparable in surgical and demographic data

single-shot TPVB (ultrasound guided) combined with intravenous analgesia (P)

20 mL of 0.25% ropivacaine (Naropin, AstraZeneca, Gothenburg, Sweden) combined with 1 µg/kg dexmedetomidine (Ai Bei Ning, Jiangsu Hengrui Medicine, Lianyungang, China) was injected after a gentle aspiration test for blood or air (13,14).

In these patients, the intravenous PCA (sufentanil, basal rate of 0.03 µg/ kg/h, bolus dose of 0.01 µg/kg, lockout time 15 min) was used for 48 hours postoperatively.

continuous TEA (E)

epidural infusion of sufentanil (0.2 μg/mL) and ropivacaine 0.06% was started at 5–10 mL/h before the skin incision and maintained during the operation. Within 48 hours after the operation, the epidural patient-controlled analgesia (PCA) (0.06% ropivacaine + 0.2μg/mL sufentanil, basal rate was 5 mL/h, 3 mL PCA at a lock-out time of 30 minutes) was used.

Length of follow-up:

12 months post operation

Loss-to-follow-up:

Before allocation

I: 3 (of 48)

Reason did not receive allocated intervention due to inoperability (2) and reoperation (1)

C: 3 (of 48)

Reason did not receive allocated intervention due to inoperability

After allocation

Intervention:3

Reasons 3 death

Control: 4

Reasons 4 death

Incomplete outcome data:

Intervention:0

Control: 0

Postoperative pain

Verbal Rating Scale (VRS: 0 for no pain, and 10 for the worst pain) at rest and during coughing at 6, 24 and 48 h

Outcome data presented in box plots

6h at rest (median, IQR)

I: 2 (0-3.5)
C:0 (0-1)

In mean±SD

I: 2 ± 0.875
C: 0 ± 0.25

24h at rest (median, IQR)

I: 2 (2-4)
C: 1 (0-2)

In mean±SD

I: 2 ± 0.5
C: 1 ± 0.5

48h at rest (median, IQR)

I: 2 (0,5-2,5)
C: 1 (0-2)

In mean±SD

I: 2 ± 0.5
C: 1 ± 0.5

>< 

6h at coughing (median, IQR)

I: 2 (1-5)
C: 0 (0-2)

In mean±SD

I: 2 ± 1
C: 0 ± 0.5

24h at coughing (median, IQR)

I: 5 (3-6)
C: 3 (2-4)

In mean±SD

I: 5 ± 0.75
C: 3 ± 0.5

48h at coughing (median, IQR)

I: 3 (2-5)
C: 3 (1,5-4)

In mean±SD

I: 3 ± 0.75
C: 3 ± 0.625

Chronic pain

Verbal Rating Scale (VRS: 0 for no pain, and 10 for the worst pain) at rest at 3, 6 and 12 months

Outcome data presented in box plots

3m at rest (median, IQR)

I: 1 (0-2)
C: 0 (0-1)

6m at rest (median, IQR)

I: 0 (0-2)
C: 0 (0-1)

12m at rest (median, IQR)

I: 0 (0-1)
C: 0 (0-0)

Study objective: to evaluate the impact of single-shot TPVB combined with intravenous analgesia versus continuous thoracic epidural analgesia (TEA) on chronic pain incidence after thoracotomy

Study conclusion: In conclusion, our results show that patients who received continuous TEA had less acute pain intensity within 24 hours after operation and lower chronic pain incidence at rest at 3 and 12 months postoperation when compared with single-shot TPVB combined with intravenous analgesia. In addition, acute pain intensity within 24 hours postoperation appears to be a predictor of chronic pain. Therefore, these results suggest the importance of aggressive management of acute pain postoperation, not only for the immediate benefit but possibly also to prevent the transition to chronicity.

Tamura, 2017

Type of study:

RCT

Setting and country: single centre, Japan

Funding and conflicts of interest: not reported

Inclusion criteria:

lung cancer patients scheduled for elective single-side lung lobectomy with antero- or verticalaxillary incision were recruited during an 18-month period. The patients were aged 20–80 years and had an American Society of Anesthesiologists physical status of I–II.

Exclusion criteria: The exclusion criteria were the same as those in our previous study [10] with the following additional criteria applied: combined resection of parietal pleura, coagulation disorder, thrombocytopenia, anti-coagulation therapy, and heart failure

Surgery: single-side lung lobectomy

N total at baseline:

(analyses)

Intervention: 36

Control: 36

Important prognostic factors²:

For example

age ± SD:

I: 67.1 ± 8.7

C: 66.9 ± 9.7

Sex (male:female):

I: 29:7

C: 28:8

Groups comparable at baseline? Yes, demographic data and surgical characteristics, including duration of anesthesia, operation, and hospitalization, were comparable in both groups

PVB catheter (P)

20 mL of 0.375% ropivacaine was administered as a bolus, followed by a 300-mL of continuous infusion of 0.2% ropivacaine at 5 mL/h

Epidural catheter (E)

5 mL of 0.375% ropivacaine (Anapeine injection; AstraZeneca K.K.) was administered as a bolus, followed by a 300-mL continuous infusion of 0.2% ropivacaine using an infusion pump (Multirate Infusor LV; Baxter Healthcare Co. Inc., Deerfield, IL) at 5 mL/h

Length of follow-up:

42h

Loss-to-follow-up:

Intervention: 4 of 40

Reason: withdrawal

Control: 4 of 40

Reason: withdrawal

Incomplete outcome data:

Intervention: 0

Control: 0

Postoperative pain

visual analog scale (VAS) while coughing, moving, and at rest 2 h after the bolus injection of ropivacaine; these evaluations were also performed at 1, 6, 12, 18, and 42 h after the injection. The VAS consisted of a 100-mm line (0 mm, no pain; 100 mm, worst pain imaginable).

Outcome data presented in line charts that are not readable.

All mean VAS scores in group E were significantly lower than those in group P throughout the observation period.

Study objective: to evaluate analgesic efficacy between paravertebral block via the surgical field (PVB-sf), in which the catheter was inserted into the ventral side of the sympathetic trunk in the paravertebral space by a thoracic surgeon under thoracoscopic visualization, and epidural block (Epi) using ropivacaine for post-thoracotomy pain relief

Study conclusion: In conclusion, Epi was superior to PVB-sf, in which the catheter was inserted into the ventral side of the sympathetic trunk in the paravertebral space, for post-thoracotomy pain management, as indicated by differences in the effective sensory block range of local anesthetics.

PVB versus Epidural anesthesia - VATS

Ding, 2018

Type of study:

RCT

Setting and country: single centre, China

Funding and conflicts of interest: funding: First Excellent Young People Project of the Second Hospital of Harbin Medical University

IC: The authors declare that they have no competing interests.

Inclusion criteria: patients classified as American Society of Anesthesiology Physical Status I/III undergoing elective video-assisted thoracoscopic lobectomy. Patients included in the study were between the ages of 18 and 70 years; had no neurologic or psychiatric illnesses, renal or hepatic insufficiency, pregnancy, diabetes, allergy to local anesthetics, or coagulation abnormalities; and were not undergoing anticoagulant therapy.

Exclusion criteria:

Not reported

Surgery: elective video-assisted thoracoscopic lobectomy

N total at baseline: (analyses)

Intervention: 36

Control: 32

Important prognostic factors²:

For example

age ± SD:

I: 56.7 ± 9.3

C: 53.1 ± 10.9

Sex (% male):

I: 63.9

C: 46.9

Groups comparable at baseline? There were no differences between groups in terms of patient, surgery, and PVB characteristics and intraoperative data

single-dose thoracic paravertebral analgesia

single-dose 0.5% ropivacaine PVB before the operation combined with the PCIA (0.01 μg/kg demand dose and 15 min lockout period with 0.03 μg/kg/h background infusion) after extubation during the 48-h postoperative period

Thoracic epidural analgesia

intraoperative thoracic epidural anesthesia with 0.5% ropivacaine and a single dose of epidural morphine (0.03 mg/kg) after extubation, combined with the same PCIA scheme.

Length of follow-up:

48h

Loss-to-follow-up:

I: 2

Reasons: 1 thoractomy, 1 sensory block level did not reach the required level

C: 3

Reasons: 2 thoractomy, 1 sensory block level did not reach the required level

Incomplete outcome data:

Intervention:0

Control: 0

Postoperative pain

Verbal rating score (VRS; scale of 0–10, with 0 indicating no pain and 10 indicating the worst pain imaginable) was assessed at 2, 6, 12, 24, 36, and 48 h after surgery at rest and after coughing.

Data in figure, not readable

Postoperative opioid consumption

total dose of sufentanil used during the 48-h postoperative period

Data in figure, not readable

Adverse events

Hypotension n (%)

I: 5, 13.9

C: 11, 34.4

Study objective: to investigate the postoperative analgesic effect of TEA, PVB, and PVB with dexmedetomidine in patients undergoing thoracoscopic lobectomy

Kosiński, 2016

Type of study:

RCT

Setting and country: single centre, Poland

Funding and conflicts of interest: not reported

Inclusion criteria: patients qualified for VATS lobectomy due to cancer, aged 18-85 years, of both genders, ASA I-III, an understanding of the principles of VAS pain assessment and no chronic pain

Exclusion criteria: technical failures to insert an epidural or paravertebral catheter, abandonment of resection (e.g., in cases of neoplastic dissemination), conversion of VATS to thoracotomy, anatomical obstacles to drug distribution found intraoperatively, cases in which the VAS assessment of pain severity was infeasible (e.g., postoperative delirium), use of other drugs affecting pain sensations, artificial lung ventilation, discontinuation of local anaesthesia for technical reasons (e.g., catheter slipping out or damage), and the use of drugs or doses that were not included in the study protocol.

Surgery: Video-assisted (VATS) lung lobectomy

N total at baseline:

(for analysis)

Intervention: 26

Control: 25

Important prognostic factors²:

Age, mean (range):

I: 64.7 (44–73)

C: 59.9 (28–78)

Sex (female):

I: 12 (46%)

C: 10 (40%)

Groups comparable at baseline? yes

PVB

continuous infusion of 0.25% bupivacaine with epinephrine, intravenous ketoprofen and paracetamol

TEA

continuous infusion of 0.25% bupivacaine with epinephrine, intravenous ketoprofen and paracetamol

Length of follow-up:

72h

Loss-to-follow-up:

Intervention: 11

Reasons: 1 failure of installation; 7 lesser extent of resection; 1 non-standard technique; 1 postoperative artificial ventilation; 1 technical failure.

Control: 16

Reasons: 7 failure of installation; 1 resection abandonment; 1 lesser extent of resection; 3 conversions to thoracotomy; 1 postoperative artificial ventilation; 2 violations of protocol; 1 technical failure.

Incomplete outcome data:

n.a.

Postoperative pain

VAS was evaluated 1, 4, 8, 24, 36, 48 and 72 h after the procedures using a standard ruler. In each case, static (at rest) and dynamic assessments (on cough).

data provided in graphs, not readable.

Significant differences were found in the measurements at 24 h — both at rest and on coughing (P = 0.01 and P = 0.023, respectively) — and in static pain at 36 h and 48 h (P = 0.025 and P = 0.026, respectively).

Postoperative opioid consumption

Postoperative morphine dosage (Emergency PCA-administered morphine doses (mg h-1))

data provided in graphs, not readable.

The comparative analysis of both groups did not reveal any significant differences in the postoperative morphine dosage. The mean dose was 0.4 mg h-1 on day 0, 0.37 mg h-1 on day 1, 0.21 on day 2 and 0.14 mg h-1 on day 3

Adverse events
hypotension (n)

I: 2

C: 8

epidural blocks were performed using the classic paramedian approach technique, whereas paravertebral blocks were performed according to the Eason and Wyatt method.

Study objective: to compare the analgaesic efficacy of continuous thoracic epidural block (TEA) and percutaneous continuous paravertebral block (PVB) in patients undergoing video-assisted lung lobectomy.

Study conclusion:

1. Pain following VATS lobectomy is severe and requires the use of complex techniques of postoperative analgaesia, including the methods of regional anaesthesia. 2. Continuous paravertebral block using the classical landmark puncture technique is as equally effective as epidural block for multimodal analgaesia. 3. Continuous paravertebral block has a better profile of safety than epidural block, which is particularly visible in the lower incidences of hypotension and urinary retention

Lai, 2021

Type of study: RCT

Setting and country: single centre, China

Funding and conflicts of interest: funding: not reported, CI: All authors have no conflict of interests to declare.

Inclusion criteria: patients aged 18–80 years old who were undergoing VATS lobectomy, American Society of Anesthesiologists (ASA) physical status class I–III, an understanding of the principle of visual rating scale (VAS) pain assessment and no chronic pain.

Exclusion criteria: patients who were on anticoagulation, patients taking opioids for greater than three weeks prior to surgery, patients with a contraindication to regional anesthesia such as infection close to the site of puncture, allergy to local anesthetics, and those with a history of chronic pain, severe cardiovascular disease, liver or renal insufficiency, a change in surgery type, conversion of VATS to thoracotomy, accidental catheter slipping, and patient refusal.

Surgery: VATS lobectomy

N total at baseline:

Intervention: 43

Control: 43

Important prognostic factors²:

For example

age ± SD:

I: 59 ± 9

C: 57 ± 9

Sex (% female):

I: 16 (37.2)

C: 20 (46.5)

Groups comparable at baseline? There were no significant differences between the two groups in terms of demographics

continuous paravertebral analgesia (P)*

Patients in the paravertebral group received an initial bolus of 0.5% ropivacaine 0.1 mL/kg and then 0.1 mL/kg/h infusion for 48 h postoperatively.

continuous epidural analgesia (E)*

The epidural infusion consisted of ropivacaine 0.15% with 6 mcg/mL of hydromorphone and was administered via a pump (Opon, Jiangsu aipeng Medical Technology Co., Ltd, Nantong, China) starting at 2 mL/h for 48 h postoperatively.

Length of follow-up:

72h

Loss-to-follow-up:

Randomization: n = 46

Intervention: 3

Reasons: 1 converted to open procedure; 2 catheter slipping out

Randomization: n = 45

Control: 2

Reasons: 1 converted to open procedure; 1 catheter slipping out

Incomplete outcome data:

Intervention: 0 (of 43)

Control: 0 (of 43)

Postoperative pain

at rest and on coughing using an 11-point VAS scale (0 = no pain, 10 = worst imaginable pain).

Data is provided in figures (line chart) that is not readable.

The comparative analysis of pain using GLM demonstrated slight intergroup differences. The U test showed significant differences in pain at 24 h at rest and on coughing (P = 0.001 and P < 0.001, respectively). There were no differences between the two groups at other time points.

Postoperative opioid consumption

Cumulative oxycodone consumption 24h (mg) (mean ± standard deviation)

I: 8.7 ± 1.3

C: 4.0 ± 1.3

To MME (conversion factor 1.5):

I: 13.05 ± 1.95

C: 6 ± 1.95

Adverse events

Hypotension (number of patients (%))

I: 2 (4.7)
C: 14 (32.6)

Study objective: to compare the analgesia efficacy and side effects of continuous paravertebral analgesia and continuous epidural analgesia for postoperative pain after VATS lobectomy

* All patients also benefited from IV patient controlled analgesia (PCA) of oxycodone 50 mg and palonosetron 0.075 mg mixed with normal saline to a total volume of 100 mL. The disposable PCA device was set to deliver no background infusion and 2 mL on-demand bolus with a lockout time of 5 min.

Study conclusion:

Though TEA has more adverse events than PVB, it is more analgesic effective than PVB in patients undergoing VATS lobectomy. TEA may be superior to PVB in patients undergoing thoracoscopic lobectomy.

Okajima, 2015

Type of study:

RCT

Setting and country: single centre, Japan

Funding and conflicts of interest: not reported

Inclusion criteria: consecutive patients (age: 18–75 years) with ASA physical status I–III scheduled for VATS with an axillary skin incision of 6–8 cm at Nishi-Kobe Medical Center in Kobe, Japan, between August 2008 and October 2009.

Exclusion criteria: allergy to non-steroidal anti-inflammatory drugs (NSAIDs) or LA, renal or hepatic failure, body mass index over 30 kg/m2 , infection at injection site, coagulative abnormality, and inability to comprehend pain scoring

Surgery: video-assisted thoracic surgery (VATS) (i.e., lung surgery including lobectomy, segmentectomy, wedge resection)

N total at baseline:

(complete data)

Intervention: 36

Control: 33

Important prognostic factors²:

For example

age ± SD:

I: 61.0 ± 15.9

C: 63.0 ± 11.1

Sex (m/f):

I: 20/16

C: 24/9

Type of surgery

Lobectomy

I: 11

C: 15

Segmentectomy I: 2

C: 2

Wedge resection

1: 23

C: 16

Groups comparable at baseline? patients’ characteristics did not differ between the two groups

ultrasound-guided PVB

three single blocks with 5 ml of 0.5 % ropivacaine

TEB with the addition of fentanyl to ropivacaine

An epidural bolus dose (5–7 ml) of 0.25–0.375 % ropivacaine was administered before skin incision

Length of follow-up:

POD2

Loss-to-follow-up:

Intervention: 9

Reason : Extended resection(n=4) Failed blocks(n=4) Cancelled operation(n=1)

Control: 9

Reason: Extended resection(n=9) Re-operations(n=1 ) Failed blocks(n=1) Postoperative renal failure(n=1)

Incomplete outcome data:

Intervention:

N (%)

Reasons (describe)

Control:

N (%)

Reasons (describe)

Postoperative pain*

verbal rating scale for pain at rest (VRS; 0 = none, 10 = maximum pain)

Outcome data presented in box plots

0h (median, IQR)

I: 1,5 (0-6)

C: 4 (0-7)

6h (median, IQR)

I: 1 (0-3)

C: 1 (0-3,25)

12h (median, IQR)

I: 1 (0-3)

C: 1 (0-1,25)

24h (median, IQR)

I: 1 ( 0-3)

C: 1 (0-2)

POD2 (median, IQR)

I: 1 (0-3)

C: 1 (0-3,5)

Postoperative opioid consumption

Postoperative consumptions of fentanyl

I: 0.6 ± 0.14 mg

C: 0.6 ± 0.16 mg

Adverse events

Hypotension

I: 1 of 36

C: 7 of 33

Study objective: to compare postoperative analgesia, side effects, and complications between ultrasound-guided PVB (USG-PVB) and TEB with the addition of fentanyl to ropivacaine after lung surgery

* When the patients suffered from severe pain despite this protocol for analgesia, intravenous fentanyl was administered and then those patients were withdrawn from this study

Study conclusion: In conclusion, USG-PVB provided similar postoperative analgesia to TEB for patients undergoing VATS. PVB had better advantages in terms of the maintenance of hemodynamics and the prevention of hypotension. On the other hand, PVB combined with fentanyl caused a high incidence of PONV, similarly to TEB, so further trials are required to search for an adequate dosage. We conclude that USG-PVB and TEB are similarly acceptable for postoperative analgesia after VATS.

Yeap, 2021

Type of study: RCT

Setting and country: single centre, USA

Funding and conflicts of interest: Funding: Indiany University; IC: The authors declare no conflicts of interest

Inclusion criteria: All VATS cases scheduled by thoracic surgeons at Indiana University Health-University Hospital , American Society of Anesthesiologists (ASA) classes 1 to 4, ≥18 years of age, and patient desiring regional anesthesia for adjunct postoperative pain control.

Exclusion criteria: contraindication to TEA or PVB, history of substance abuse in the prior 6 months, opioid tolerance, necessitation for intubation after surgery, and known allergy or contraindication to any study medications (oxycodone/acetaminophen, bupivacaine, or ropivacaine)

Surgery: VAT

N total at baseline:

I1: 40

I2: 40

C: 40

Important prognostic factors²:

For example

age ± SD:

I1: 63.5 (48.5-70.0)

I2: 62.0 (45.5-69.5)

C: 61.0 (52.0-70.0)

Sex (female):

I1: 16 (40.0%)

I2: 19 (47.5%)

C: 25 (62.5%)

Groups comparable at baseline? All characteristics were similar among groups except for over-representation (p = 0.026) by Caucasian race in the TEA group (97.5% v 80.0% and 82.5% for single-injection PVB or PVB catheter, respectively). Also, the median time to place the PVB catheter (12.0 min) was longer than the time required for the singleinjection PVB (6.0 min) or TEA (5.0 min; p < 0.001).

I1: Ultrasound-guided PVB catheter

Ropivacaine, 0.2%, was delivered postoperatively at a rate of 10 mL/h by infusion pump (OnQ Pain Relief System, Kimberly-Clark, Roswell, GA)

I2: ultrasound-guided single-injection PVB

30 mL of 0.5% ropivacaine

TEA

epidural mixture of 0.125% bupivacaine and 0.05 mg/mL of hydromorphone (starting at the end of the surgery)

Length of follow-up:

6 months

Loss-to-follow-up:

53 in total for 6 month measurement

I1: 17

I2: 18

C: 18

Reason: not described.

Incomplete outcome data:

Not reported

Postoperative pain

visual analog scale pain scores (at rest and with knee flexion)

1h – rest in median (IQR)

I1: 5.0 (3.0-8.0)

I2: 6.0 (3.5-8.0)

C: 6.0 (3.5-8.0)

24h - rest in median (IQR)

I1: 4.0 (3.0-5.5)

I2: 4.5 (2.5-6.0)

C: 3.0 (1.0-5.0)

48h - rest in median (IQR)

I1: 3.0 (1.0-5.0)

I2: 4.0 (2.0-6.0)

C: 2.0 (1.0-4.0)

1h – knee flexion in median (IQR)

I1: 6.5 (4.0-9.0)

I2: 7.0 (5.0-9.0)

C: 7.0 (5.0-9.0)

24h - knee flexion in median (IQR)

I1: 6.5 (5.0-8.0)

I2: 7.0 (5.0-8.0)

C: 6.0 (2.0-7.0)

48h - knee flexion in median (IQR)

I1: 5.0 (3.0-7.0)

I2: 6.0 (3.0-8.0)

C: 4.0 (2.0-6.0)

Postoperative opioid consumption

morphine milligram equivalents [MME]

24h in median (IQR)

I1: 88.0 (34.5-143.0)

I2: 75.5 (30.5-121.8)

C: 15.0 (0-30.0)

In mean±SD
i1: 88 ± 27,125

I2: 75.5± 22,825

C: 15.0 ±7,5

Chronic pain at 6 months (n=67)
surveyed by telephone

(single-injection PVB, n = 23; PVB catheter, n = 22; TEA, n = 22)

Chronic postsurgical pain indicators (based on 13 survey questions) were similar for all 3 groups.

Study objective: to compare adjunct analgesic modalities for VATS, including paravertebral nerve blockade (PVB) and thoracic epidural anesthesia (TEA).

Study conclusion: In conclusion, pain scores and opioid consumption after VATS procedures were lower with TEA than either PVB technique. Although these results support TEA as the superior technique, the small difference in pain scores may not be clinically significant, and the risk of rare adverse events with TEA might lead one to consider single-injection PVB. In the authors’ institution, single-injection PVB is performed for most VATS cases owing to the shorter placement time and lower risk for serious adverse events. Clearly, use of PVB catheters adds no benefit and cannot be justified.