The use of epidural analgesia in Video-Assisted thoracic Surgery

Epidural catheter insertion for pain relief is a standard procedure practiced by most anesthesiologists worldwide. It is used for pain management to supplement general anesthesia for surgical procedures and to provide analgesia in intraoperative, postoperative, peripartum, and endof-life settings. When our group started this project in 2015, epidural analgesia was the de facto golden standard for managing pain after Video-Assisted Thoracic Surgery (VATS), probably historically rooted in the previous use of thoracotomy for this type of surgery. Evidence on the need for epidural analgesia in videoscopic thoracic surgery was scarce, its justification was being questioned, and some thoracic centers were abandoning its use in favor of other alternative methods of perioperative pain management.
The standard of care for lung cancer patients in our department was the use of a thoracoscopic surgical approach and a multimodal setup for perioperative pain management, including the use of epidural analgesia. We wanted to study some of the missing pieces of evidence on the use of epidural analgesia in VATS in order to examine the feasibility of abandoning its use altogether, this way eliminating all risks and possible side effects associated with it. In our initial trial, we studied the level of pain after VATS using epidural analgesia for postoperative pain management and compared it to the level seen when using morphine in stead. We also examined epidural analgesia’s impact on the immune response after surgery and compared it to using opioids as an alternative. Finally, we did an observational study on the epidural insertion procedure examining some of the lesser known, not previously addressed aspects of this procedure.
Our study on pain showed patients experienced notably more postoperative pain after VATS using opioid-based pain management compared to using epidural analgesia, the difference being both statistically significant and clinically relevant. The study on the immunological response to using epidural analgesia or oral morphine for pain management in VATS did not find any significant differences between the two treatment groups, neither on postoperative cytokine levels nor on postoperative survival. The observational study showed the epidural catheter insertion procedure for epidural analgesia to be expedient and associated with only mild pain in most cases. Procedure-related pain was significantly less than expected by the patients, but was significantly related to these expectations. The number of procedural attempts required for insertion influenced the experienced pain, but the physician’s clinical experience did not. Long-term procedural sequelae were seen in only a minority of the patients.
Overall, the studies have contributed with new knowledge regarding the use of epidural analgesia in VATS for lung cancer patients but have also given an insight into some aspects of its use in a broader context. The results from the study on postoperative pain and immune response are specific for videoscopic thoracic surgery, but the study on the epidural insertion procedure should be applicable in other settings.