Author: Michael Vlessides
When it comes to video-assisted thorascopic surgery (VATS) for lobectomy, a study has found that patients who underwent thoracic epidural analgesia used more than 40% less opioids in the first two postoperative days than their counterparts receiving surgical site infiltration with liposomal bupivacaine. The researchers acknowledged, however, that more and larger studies are required to corroborate these findings in this surgical population.
“Although thoracic epidural analgesia is considered the gold standard for postoperative pain control in thoracic surgery, it is associated with the undesirable risks of hypotension, urinary retention and bleeding,” said Jacklynn Sztain, MD, an assistant clinical professor of anesthesiology at the University of California, San Diego. “This has led many on a quest to find an acceptable alternative. Surgical site infiltration with liposomal bupivacaine has been suggested as comparable to thoracic epidural analgesia for patients undergoing thoracic surgeries.”
To determine the relative effectiveness of the two therapeutic approaches, Dr. Sztain and her colleagues manually extracted data for patients undergoing a VATS lobectomy by a single surgeon at the University of California, San Diego Medical Center between January 2014 and November 2017. The study’s primary outcome was total opioid requirements in the first two days after surgery, measured by IV morphine equivalents. The choice of analgesic was at the surgeon’s discretion.
A total of 45 patients were included in the analysis, of whom 14 received surgical site infiltration and 31 received the thoracic epidural. Despite the differences in numbers of participants, the two groups proved comparable on age, sex and body mass index.
The analysis revealed that the median (interquartile range, 25%-75%) total opioid consumption between postoperative days 0 and 2 was 28.0 mg in the thoracic epidural group (12.0-52.0 mg) and 49.5 mg (35.0-70.5 mg) in the surgical site infiltration group (P=0.03). Similar results were found between postoperative days 0 and 1, where median total opioid consumption was 20.0 mg (9.5-37.0 mg) among thoracic epidural patients and 41.0 mg (28.5-59.8 mg) among those given the surgical site infiltration (P=0.004).
Despite these significant differences, there was no difference in the average reported numeric rating scale pain scores during any time period. Similarly, hospital length of stay did not differ, although there was a trend toward a longer stay in the liposomal bupivacaine group.
“In an effort to minimize unwanted side effects and complex management of thoracic epidurals, surgical site infiltration of liposomal bupivacaine has been suggested as a safe and effective alternative,” Dr. Sztain said. “In this retrospective analysis, however, the patients consumed 43.4% less opioids on postoperative days 0 to 2 with a thoracic epidural compared to surgical site infiltration.
“We believe that further prospective randomized trials are needed to further demonstrate the superiority of thoracic epidural analgesia as well as to compare side effects,” she said.
Session moderator Joseph M. Neal, MD, a staff anesthesiologist at Virginia Mason Medical Center, in Seattle, questioned the nature of the participants’ pain. “I’m curious about the pain they were having. Was it chest tube pain or was it thoracic wall pain?”
“The difference is that with the liposomal bupivacaine group, they usually had chest wall or chest tube pain,” Dr. Sztain replied. “However, in the epidural group, their pain was actually shoulder pain.”
“It’s interesting that you weren’t having shoulder pain in the surgical site infiltration group,” Dr. Neal added.