Neoplasms

Respiratory Tract (Lung and Bronchial) Diseases

All Conditions

Symptoms and General Pathology

Nervous System Diseases

Lung Neoplasms

Pain, Postoperative

Pain

Postoperative Complications

Neurologic Manifestations

Central Nervous System Depressants

All Drugs and Chemicals

Analgesics

Pharmaceutical Solutions

Herbal and Botanical

Anesthetics

Bupivacaine

Ropivacaine

Anesthetics, Local

Levobupivacaine

Analgesics, Opioid

After correct placement of the epidural catheter, a local anaesthetic (ropivacaine, levobupivacaine or bupivacaine) will be started and, according to in house protocols, an opioid will be added to the epidural solution. A provisional stop of the administration of the epidural infusion is planned after 48 hours (on the second postoperative day).

Thoracic epidural analgesia

The PVB catheter is placed under general anaesthesia at the beginning of the VATS procedure under direct thoracoscopic vision. The level of the PVB catheter placement is chosen at the intercostal space of the largest incision (mostly thoracic level 4 or 5). Under direct thoracoscopic vision, the surgeon inserts a Touhy needle. The tip of the needle is observed beneath the pleural surface thoracoscopically. Injection of about 2 mL ropivacaine 7.5mg/mL will create subpleural hydrodissection to reach the adequate paravertebral plane for placement of the catheter. The PVB catheter is subsequently placed under direct thoracoscopic vision and left next to the sympathetic chain in the paravertebral space. Next, a bolus of ropivacaine (total amount 20 mL including the given amount for hydrodissection) is given through the catheter.

Postoperatively, a ropivacaine 2 mg/mL pump for continuous infusion is given with an infusion rate of 8-14 ml/hour.

Continuous regional paravertebral block

At the end of the surgery a single shot ICNB will be placed at 9 levels (thoracic level 2 to 10) with 2-3mL local anaesthetics per intercostal space under direct thoracoscopic vision. The injection site will be chosen just lateral from the sympathetic trunk. This group will have no analgesic catheters for continuous analgesia. No mobility restrictions are instructed in this group.

Single shot intercostal nerve block

Adequate pain control after video-assisted thoracoscopic surgery (VATS) for lung resection is important to improve postoperative mobilisation, recovery, and to prevent pulmonary complications. So far, no consensus exists on optimal postoperative pain management after VATS anatomic lung resection.

Thoracic epidural analgesia (TEA) is the reference standard for postoperative pain management following VATS. Although the analgesic effect of TEA is clear, it is associated with patient immobilisation, bladder dysfunction and hypotension which may result in delayed recovery and longer hospitalisation. These disadvantages of TEA initiated the development of unilateral regional techniques for pain management. The most frequently used techniques are continuous paravertebral block (PVB) and single-shot intercostal nerve block (ICNB).

The investigators hypothesize that using either PVB or ICNB is non-inferior to TEA regarding postoperative pain and superior regarding quality of recovery (QoR). Signifying faster postoperative mobilisation, reduced morbidity and shorter hospitalisation, these techniques may therefore reduce health care costs and improve patient satisfaction.

This is a multi-centre randomised three-arm trial comparing continuous PVB, single-shot ICNB and TEA in a 1:1:1 ratio in patients who will undergo a VATS anatomic lung resection. We use a non-inferiority design with respect to the outcome measure 'pain' and a concomitant superiority design regarding 'quality of recovery'.

As the analgesic strategies highly differ in nature (with or without percutaneous catheter) and/or postoperative care (mobility with or without prerequisites, urinary catheter placement), blinding for the randomised strategy is unfeasible.

Optimal Postoperative Pain Management After Lung Surgery (OPtriAL)

Optimal Postoperative Pain Management After Lung Surgery (OPtriAL): Multi-centre Randomised Trial

Data will become available for non-commercial scientific research (open access) after a period of 12 months after the last data collection. Data request can be done by contacting the PI.

Proportion of pain scores ≥4 as assessed by the numerical rating scale (NRS) (measured from 0 until 10; lowest value signifying no pain and highest value signifying worst pain)

QoR measured with the QoR-15 questionnaire on postoperative 1 and 2 (maximum score of 150, the higher the score the better the outcome)

total opioid and non-opioid consumption as supplementary analgesic requirement

according to the Clavien-Dindo classification;

defined as the total number of days in hospital after the surgical intervention (including readmissions within the first 30 postoperative days), the following standardised discharge criteria after surgery will be applied in all participating hospitals: normal intake of nutrition, independent mobility, absence of fever (\<38 °C), and no presence of chest tube;

5-point Likert scale: not at all satisfied, slightly satisfied, neutral, very satisfied and extremely satisfied

4-point scale: on the bed (1), to the chair (2), to the toilet (3), outside the patient's hospital room(4)

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization	Link
Optimal Postoperative Pain Management After Lung Surgery (OPtriAL)	NCT05491239	Lung Cancer Pain, Postopera... VATS Locoregional An... Thoracic Epidur...	Thoracic epidur... Continuous regi... Single shot int...	18 Years -	Maxima Medical Center
Optimal Postoperative Pain Management After Lung Surgery (OPtriAL)	NCT05491239	Lung Cancer Pain, Postopera... VATS Locoregional An... Thoracic Epidur...	Thoracic epidur... Continuous regi... Single shot int...	18 Years -	Maxima Medical Center

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