Enhanced recovery pathways in thoracic surgery from Italian VATS Group: perioperative analgesia protocols

Abstract

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive technique that allows a faster recovery after thoracic surgery. Although enhanced recovery after surgery (ERAS) principles seem reasonably applicable to thoracic surgery, there is little literature on the application of such a strategy in this context. In regard to pain management, ERAS pathways promote the adoption of a multimodal strategy, tailored to the patients. This approach is based on combining systemic and loco-regional analgesia to favour opioid-sparing strategies. Thoracic paravertebral block is considered the first-line loco-regional technique for VATS. Other techniques include intercostal nerve block and serratus anterior plane block. Nonsteroidal anti-inflammatory drugs and paracetamol are essential part of the multimodal treatment of pain. Also, adjuvant drugs can be useful as opioid-sparing agents. Nevertheless, the treatment of postoperative pain must take into account opioid agents too, if necessary. All above is useful for careful planning and execution of a multimodal analgesic treatment to enhance the recovery of patients. This article summarizes the most recent evidences from literature and authors' experiences on perioperative multimodal analgesia principles for implementing an ERAS program after VATS lobectomy.

Keywords: Regional analgesia; pain management; video-assisted thoracoscopic surgery (VATS).

Figure 1

Schematic representation of post-operative pain management strategy after VATS lobectomy. The pre-operative patient assessment allows to set the analgesic plan. The cornerstone is always the inclusion of a loco-regional technique. Thoracic epidural analgesia should be considered if there is a high risk of conversion to thoracotomy. Otherwise thoracic paravertebral block is considered the first-line loco-regional technique. If not feasible, it can be replaced with intercostal nerve block or serratus anterior plane block. These techniques must be always integrated with systemic analgesia to meet the criteria of multimodal analgesia. LR, loco-regional; TEA, thoracic epidural analgesia; TPVB, thoracic paravertebral block; ICNB, intercostal nerve block; SAPB, serratus anterior plane block; NSAID, nonsteroidal anti-inflammatory drug; PCA, patient-controlled analgesia; VATS, video-assisted thoracoscopic surgery.