Work

Opioid use and abuse following video-assisted thoracic surgery (VATS) or thoracotomy lung cancer surgery

Year: 2019

Type: article

Abstract: Although opioids are frequently prescribed in the postoperative setting, the call for increased opioid stewardship among surgeons has only recently become more urgent.Recent studies have shown that opioids are overprescribed postoperatively (1,2).Given that the risk of chronic opioid use and consequently, misuse and abuse, has been demonstrated to increase with longer duration and higher dosage prescriptions, it is time for surgeons to have a proactive role in mitigating the opioid crisis (3,4).Most of the current literature to date on postoperative opioid prescribing has focused on general, gynecologic, and orthopedic surgery (1-3,5,6).Opioid prescribing patterns and implications for thoracic surgery remain mostly undefined. Post-thoracic surgery pain and analgesiaPostoperative pain after thoracic surgery is uniquely challenging both in the acute and long-term setting.The observed high rate of pain has been attributed to rib spread and intercostal nerve damage intraoperatively.In the immediate postoperative setting, inadequate postoperative pain control may increase splinting, inadequate coughing and impaired respiratory mechanics resulting in increased hypoxia, atelectasis and infection (7).Furthermore, chronic pain post-thoracotomy has been reported in up to 80% of patients within 6 months of surgery and 30-50% up to 5 years postoperatively (8-11).Given that acute postoperative pain after thoracic surgery has been associated with increased likelihood of chronic pain, aggressive perioperative pain control is very important (12).A multimodal, multidisciplinary approach involving regional and systemic perioperative analgesia has become standard to mitigate postoperative pain.Regional pain control may be achieved by several mechanisms.Preoperative placement of a thoracic epidural with infusion of local anesthetic and/or opioids is the current standard, used intraoperatively and for postoperative patientcontrolled analgesia.However, complications of thoracic epidural, including hypotension, epidural hematoma and urinary retention, as well as failure rates of 14-30%, have made paravertebral blockade an attractive alternative with similar analgesia achieved and a lower minor complication rate (11).In the current era of video-assisted thoracic surgery (VATS) and associated smaller incisions without need for rib spreading, alternative methods of local pain control have been utilized to avoid the potential associated complications with thoracic epidural.Intracostal nerve block may be performed under direct vision intraoperatively (13).Alternatively, intercostal catheter placement has also been described as an alternative mechanism for postoperative continuous analgesic infusion that may allow for earlier hospital discharge than traditional epidural (14,15).Furthermore, as compared to traditional VATS, the advent of uniportal VATS may have the important advantage

Source: Translational Lung Cancer Research

DOI: 10.21037/tlcr.2019.05.14

Authors: Tamar B. Nobel, Prasad S. Adusumilli, Daniela Molena

Institution: Memorial Sloan Kettering Cancer Center

Language: English

Topic: Opioid Use Disorder Treatment

Subfield: Public Health, Environmental and Occupational Health

Field: Medicine

Domain: Health Sciences

SDG: Good health and well-being

Open Access status: diamond

Funder: National Cancer Institute