PROSPECT guidelines for pain management after video‐assisted thoracoscopic surgery: a reply

Thank you for the opportunity to respond to Dr Chow’s concerns [1] regarding the PROSPECT recommendations for pain management of patients undergoing videoassisted thoracoscopic surgery (VATS) [2]. First, we would like to re-emphasise that the PROSPECT methodology for the development of recommendations is unique [3]. We do not focus solely on the efficacy of an analgesic intervention. We confirm that the analgesic intervention is relevant in current clinical practice. Thus, because early mobilisation is key to enhanced recovery, effects of an analgesic intervention on ambulation are considered. Also, the balance of benefits and risks of the analgesic intervention is assessed. Furthermore, it is determined whether the invasiveness of analgesic intervention outweighs the degree of pain after the surgical procedure in question. Such rigorous approach to analysing the available evidence differentiates the PROSPECTmethodology fromothers. With respect to thoracic epidural analgesia, there is no question that it provides excellent pain relief; however, we do not recommend it because it can delay ambulation due to orthostatic hypotension, as well as the presence of catheters and pumps. Several systematic reviews and metaanalysis, including ours [4], comparing epidural analgesia and paravertebral blocks have confirmed a comparable analgesic efficacy, but with lower incidence of adverse events such as hypotension and urinary retention. These adverse events can preclude postoperative rehabilitation; therefore, the PROSPECT Working Group recommends considering paravertebral blocks. Dr Chow quotes a study by Huang et al. [5], but this suffers from several methodological flaws. Also, given the nature of the study, blinding was not possible. In addition, the study does not define the primary outcome but assesses catheter placement in the epidural space compared with the paravertebral space. Because we recommend a single injection, the conclusions of this study are not applicable. When comparing the reliability of epidural and paravertebral catheter placements, one must remember that the paravertebral catheter can be easily placed by the surgeon under direct vision. Of note, VATS is generally less painful than open thoracic surgery, and this is an additional reason why epidural analgesia, a relatively invasive technique, is not recommended when compared with other regional analgesic techniques, as stressed in our review. As for serratus anterior plane block, it was recently compared with intercostal blocks and systemic analgesics and could be considered as an alternative technique to paravertebral block, but definitive evidence is lacking. Similarly, erector spinae plane block, technically similar to a paravertebral block, could be considered. In summary, we stand by our recommendations for pain management in patients undergoing VATS. Several regional analgesic techniques such as paravertebral blocks, erector spinae plane blocks and serratus anterior plane blocks provide similar pain relief compared with epidural analgesia but without the potential adverse effects that can delay ambulation. Therefore, epidural analgesia is not recommended, even as a second-line intervention. [Correction added on 21 April 2022, after first online publication: The 5th paragraph has been removed in this version. ]