Management of post-operative pain by placement of an intraoperative intercostal catheter after single port video-assisted thoracoscopic surgery: a propensity-score matched study

Abstract

Background: The establishment of a golden standard for post-operative analgesia after thoracic surgery remains an unresolved issue. Benefiting from the rapid development of single port video-assisted thoracoscopic surgery (VATS), a good candidate for the alleviation of patients' pain is the placement of an intercostal catheter (ICC) safely after uniport VATS. We hypothesized that continual infusion through ICC could provide effective analgesia for patients with only one wound and we evaluate its postoperative analgesic function in uniport VATS patients with or without intercostal nerve blockade.

Methods: Since March 2014, 235 patients received various kinds of single port VATS. We identified 50 patients who received single port VATS with intercostal nerve blockade and retrospectively compared them with a group of patients who had received single port VATS without intercostal nerve blockade. The operative time, post operation day 0, 1, 2, 3 and discharge day pain score, narcotic requirements, drainage duration and post-operative hospital stay were collected. In order to establish a well-balanced cohort study, we also used propensity scores matching (1:1) to compare the short term clinical outcome in two groups.

Results: No operative deaths occurred in this study. The uniport VATS with intercostal nerve blockade group was associated with less post operation day 0 and day 1 pain score, and narcotic requirements in our cohort study (P<0.001, <0.001, and 0.003). After propensity scores matching, there were 50 patients in each group. Mean day 0 and day 1, day 2, day 3 pain score, drainage duration, post-operative hospital stay, and narcotic requirements were smaller in uniport VATS with intercostal nerve blockade (P<0.001, <0.001, 0.038, 0.007, 0.02, 0.042, and 0.003).

Conclusions: In conclusion, in patients post single port VATS, continual intercostal nerve block with levobupivacaine infusion appears to be a safe, effective and promising technique in our study, associated with a shorter hospital stay and less post-operative pain. Further prospective trials are needed to determine the long term outcomes.

Keywords: Minimally invasive surgery; intercostal nerve block; single port video-assisted thoracoscopic surgery (VATS).

Figure 1

(A) A 7 Fr ICC was inserted in the sub pleural space through uniport VATS wound; (B) after we insert the ICC in the sub pleural space, 10 mL levobupivacine was injected for the initial intercostal nerve block. ICC, intercostal catheter; VATS, video-assisted thoracoscopic surgery.

Figure 2

(A) The ICC and chest tube was fixed at the uniport VATS wound; (B) continual local anesthetic infusion was given (levobupivacaine 0.2%) through sub pleural catheters post operation; (C) using chest X-ray to confirm the position of ICC and chest tube post operation. ICC, intercostal catheter; VATS, video-assisted thoracoscopic surgery.

Figure 3

Before propensity score matching, patients with ICC had less pain sensation on postoperative day 0 and 1 (P<0.001). ICC: intercostal catheter.

Figure 4

After propensity score matching, patients with ICC had less pain sensation on postoperative day 0, 1, 2 and 3 (P<0.001, P<0.001, P=0.038, P=0.007). ICC, intercostal catheter.

Figure 5

After propensity score matching, patients with ICC received less IV form morphine dosage for pain control (P=0.003).