Analgesic Efficacy of Thoracoscopic Direct-View Versus Ultrasound-Guided Thoracic Paravertebral Block in Multi-Port Video-Assisted Thoracoscopic Lung Surgery: A Randomized Controlled Non-Inferiority Study

Abstract

Purpose: This study compares the analgesic effects of the Thoracoscopic Direct-view Thoracic Paravertebral Nerve Block (DTPVB) with those of the Ultrasound-guided Thoracic Paravertebral Nerve Block (UTPVB), providing a clinical reference.

Patients and methods: Sixty-eight patients undergoing three-port video-assisted thoracic surgery (VATS) with general anesthesia were randomly assigned to either the DTPVB group (Group D, n = 34) or the UTPVB group (Group U, n = 34). Both groups received a 10 mL injection of 0.75% ropivacaine at the T4 and T7 interspaces. Primary outcomes were cumulative sufentanil equivalents from the start of lung manipulation to 24 hours postoperatively, with group differences assessed against a non-inferiority margin of 5 μg (Δ). Secondary outcomes include postoperative pain scores, analgesic consumption, patient satisfaction, adverse effects, and other related indicators.

Results: The cumulative use of sufentanil equivalents from the start of lung manipulation to 24 hours postoperatively was 35.0 ± 6.1 μg in Group D and 33.2 ± 5.6 μg in Group U, with no significant difference (P = 0.217). The difference in cumulative sufentanil equivalents (Group D minus Group U) was 1.8 (95% CI -1.07, 4.65), within the non-inferiority margin of 5 (Δ). Postoperative pain scores, analgesic consumption, adverse effects, and complications were similar were similar between groups. However, DTPVB was associated with lower anxiety and higher satisfaction (P<0.001). At 15 minutes post-block, ropivacaine plasma concentrations were higher in Group D (P=0.024).

Conclusion: DTPVB, via transmural pleural puncture, was non-inferior to UTPVB in analgesic efficacy from the beginning of the manipulation of the lungs in operation to 24h postoperatively. DTPVB provides a good alternative, especially for patients who are anxious before surgery, have difficulty cooperating with UTPVB, or in cases where UTPVB puncture fails. However, when using high concentrations of ropivacaine, greater vigilance for toxicity is required.

Keywords: TPVB; VATS; pain management; thoracic paravertebral block; video-assisted thoracoscopic surgery.

Figure 1

Consolidated Standards of Reporting Trials (CONSORT) Flowchart describing patients progress through the study.

Figure 2

Non-inferiority assessment for main outcomes in groups D and U. The figure illustrates the average sufentanil equivalents from the beginning of the manipulation of the lungs in operation to end of the surgery (light blue) and within the first 24 postoperative hours (steel blue), respectively. The figure also shows the average difference in the total sum of sufentanil equivalents between these two stages (black). Error bars mark the 95% confidence intervals, and Δ represents the non inferiority margin. The shaded area to the left of Δ indicates the non-inferiority zone.

Figure 3

Plasma concentration of ropivacaine. The data shows the average plasma ropivacaine levels in groups D and U after thoracic paravertebral block at 8 time points: immediately, 5, 10, 15, 30, 45, 60, and 90 minutes. Circular or box markers represent averages, and error bars show standard error. *denotes p<0.05 between the two groups at the same time point. ^#denotes p<0.05 compared with T0 within the same group.There was a statistically significant difference between the two groups at 15 minutes after the paravertebral block (P=0.024).