Erector Spinae Plane Block or Serratus Anterior Plane (SAP) Block Following Video Assisted Thoracic Surgery
Condition: Lung Diseases
MeSH terms: Lung Diseases
Study type: Interventional

Summary: 
      Video assisted thoracic surgery (VATS) has recently been evaluated as the standard surgical
      procedure for lung surgery. Although VATS is less painful than thoracotomy, patients may feel
      severe pain during the first hours at postoperative period. Analgesia management is very
      important for these patients in postoperative period since insufficient analgesia can cause
      pulmonary complications such as atelectasis, pneumonia and increased oxygen consumption. The
      ultrasound (US) guided erector spina plane (ESP) block is a novel interfacial plan block
      defined by Forero et al. at 2016. ESP block provides thoracic analgesia at T5 level and
      abdominal analgesia at T7-9 level. Visualization of sonoanatomy with US is easy, and the
      spread of local anesthesic agents can be easily seen under the erector spinae muscle. Thus,
      analgesia occurs in several dermatomes with cephalad-caudad way. US-guided serratus anterior
      plane (SAP) block provides effective analgesia in anterior, posterior and lateral dermatomes
      of thorax. It has been reported that SAP block provides effective postoperative pain
      management following thoracotomy, breast surgery and VATS. There is no clinical randomized
      study evaluating the efficacy of ESP block and SAP block following VATS in the literature.
    

Detailed description: 
      Video assisted thoracic surgery (VATS) has recently been evaluated as the standard surgical
      procedure for lung surgery. The advantages of VATS procedures compared with open thoracotomy
      are rapid recovery, short hospital stay and low complication risk. Although VATS is less
      painful than thoracotomy, patients may feel severe pain during the first hours at
      postoperative period. Analgesia management is very important for these patients in
      postoperative period since insufficient analgesia can cause pulmonary complications such as
      atelectasis, pneumonia and increased oxygen consumption.

      The ultrasound (US) guided erector spina plane (ESP) block is a novel interfacial plan block
      defined by Forero et al. at 2016. ESP block provides thoracic analgesia at T5 level and
      abdominal analgesia at T7-9 level. The ESP block contains a local anesthetic injection into
      the deep fascia of erector spinae. This area is away from the pleural and neurological
      structures and thus minimizes the risk of complications due to injury. Visualization of
      sonoanatomy with US is easy, and the spread of local anesthesic agents can be easily seen
      under the erector spinae muscle. Thus, analgesia occurs in several dermatomes with
      cephalad-caudad way. Cadaveric studies have shown that the injection spreads to the ventral
      and dorsal roots of the spinal nerves and creates sensory blockade in both posterior and
      anterolateral thorax. In the literature, it has been reported that ESP block provides
      effective analgesia after open heart surgery, breast surgery and ventral hernia repair in
      randomized controlled studies about ESP block efficiency for postoperative analgesia
      management. In some case series and case reports it has been reported that ESP block provides
      effective analgesia after thoracotomy and VATS. Furthermore, it has been reported that it
      provides effective analgesia in chronic and persistant pain syndromes of thorax.

      US-guided serratus anterior plane (SAP) block is an interfascial plane block and was
      described by Blanco in 2013. A local anesthetic solution is performed into the fascial plane
      of serratus anterior muscle. It is easy to perform and has low complication rate because it
      is far away from the important neurological and vascular structures. The serratus anterior
      muscle may be seen easily with US guidance in the mid-axillary line. It provides effective
      analgesia in anterior, posterior and lateral dermatomes of thorax. It has been reported that
      SAP block provides effective postoperative pain management following thoracotomy, breast
      surgery and VATS. There is no clinical randomized study evaluating the efficacy of ESP block
      and SAP block following VATS in the literature.

      The aim of this study is to compare US-guided ESP block and SAP block for postoperative
      analgesia management after VATS. The primary aim is to compare perioperative and
      postoperative opioid consumption and the secondary aim is to evaluate postoperative pain
      scores (VAS), adverse effects related with opioids (allergic reaction, nausea, vomiting) and
      complications due to blocks (pneumothorax, hematoma).
    

Intervention name(s): ESP block (Group ESP); SAP block (Group SAP)
Intervention type(s): Other; Other
Intervention description(s): In group A, ESP block will be performed. US probe will be placed longitudinally 2-3 cm lateral to the T5 transverse process. From superior to inferior, three muscles will be visualized on the hyperechoic transverse process; trapezius (upper), rhomboideus major (middle), erector spinae (lower). The block needle will be inserted cranio caudal direction and then for correction of the needle 5 ml saline will be injected deep into the erector spina muscle fascia. Following confirmation of the correct position of the needle 20 ml %0.25 bupivacaine will be administered for block; In group B, after lateral positioning, US probe will be placed in a sagittal plane over the midclavicular region of the thoracic cage. Then the 7th rib will be identified in the midaxillary line, followed by the identification of the following muscles overlying the 6th rib: the latissimus dorsi (superficial and posterior), teres major (superior), and serratus muscle (deep and inferior). The needle will be inserted in-plane with respect to the ultrasound probe targeting the plane superficial to the serratus anterior muscle. 5 ml saline will be enjected for correction. Following confirmation of the correct position of the needle 20 ml %0.25 bupivacaine will be administered for block.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Fifty patients aged 18-65 years old with American Society of Anesthesiologists (ASA) classification I-II and scheduled for VATS under general anesthesia will be included in the study. Patients with a history of bleeding diathesis, receiving anticoagulant treatment, known local anesthetics and opioid allergy, infection of the skin at the site of the needle puncture, pregnancy or lactation, and patients who do not accept the procedure will be excluded from the study. Randomization will be achieved using a randomizing computer program. Patients will be randomly divided into two groups (Group A = ESP group, Group B = SAP group) including 25 patients each, before entering the operating room.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Video assisted thoracic surgery; Postoperative pain management; Erector spina plane block; Serratus anterior plane block