Optimal pain management after thoracoscopic lung surgery

This thesis evaluates postoperative pain management after video-assisted thoracoscopic surgery (VATS), focusing on alternatives to thoracic epidural analgesia (TEA), the traditional standard of care. A systematic review and meta-analysis showed that locoregional techniques, including paravertebral block (PVB) and intercostal nerve block (ICNB), provide promising pain relief, although existing evidence was too heterogeneous for firm conclusions.
To address this, the multicentre randomised OPtriAL study was set up to compared TEA, continuous PVB and single-shot ICNB in 450 patients undergoing VATS for anatomical lung resections. ICNB was demonstrated to be non-inferior to TEA for postoperative pain control, while PVB yielded inconclusive results. Quality of recovery was similar between groups, but ICNB and PVB significantly reduced opioid use and improved postoperative mobility. ICNB was also associated with a shorter hospital stay without increasing complications, supporting its use as an alternative to TEA. Cost-effectiveness analyses showed no significant differences in healthcare or societal costs between the analgesic techniques.
Patient preference research revealed that over 92% of patients were willing to accept more pain if this allowed them to avoid awake epidural placement and maintain better postoperative mobility. A retrospective study in pneumothorax surgery confirmed that ICNB resulted in comparable pain control, shorter hospitalization and earlier mobilization. Finally, a prospective cohort study found that 16% of patients experienced early persistent pain after VATS, with acute postoperative pain being an independent risk factor, emphasizing the importance of optimal early pain management to reduce the risk of persistent and chronic pain after VATS.