Is Single Level Paravertebral Analgesia Enough for Controlling Postoperative Pain in VATS?

Reply by the Authors of the Original Article

I read the article by Cioffi et al with great interest.[1] I want to express my comments on the article and paravertebral analgesia procedure.

In the article it is mentioned that the catheter is placed only into the intercostal space of the camera port level. In VATS procedures, generally three ports are used, and if a major lung resection is planned, a utility thoracotomy is added, which is approximately 5 cm long. Applying the paravertebral catheter only to the intercostal space of the camera port may be effective in thoracoscopy, but I think that a paravertebral catheter applied to only one intercostal space is not enough for controlling the postoperative pain in VATS procedures.

It is understood from the text that the catheter is placed into a subpleural space that is generated by hydrodissection. Some authors have also mentioned the usage of a pocket in the subpleural area.[2] I think that when a tent is made in the subpleural area, there is a possibility for subpleural hematoma. This hematoma may lead to localized pleural thickening. In this context, this thickening may be misdiagnosed as pleural metastasis in a malignancy patient in follow-up or this localized thickening may be investigated for suspicion of a disease in future.

As a result, the procedure of the authors may be suitable for thoracoscopy, but I think that it is not suitable for VATS procedures. In my opinion, performing a procedure that has a potential for misdiagnosis in the future should not be used for postoperative pain control.

• References

• 1 Cioffi U, Raveglia F, Rizzi A, Di Mauro P, De Simone M, Baisi A. Paravertebral analgesia in video-assisted thoracic surgery: a new hybrid technique of catheter placement for continuous anesthetic infusion. Thorac Cardiovasc Surg 2014; . doi:10.1055/s-0034-1396426. [Epub ahead of print]
• 2 Komatsu T, Sowa T, Takahashi K, Fujinaga T. Paravertebral block as a promising analgesic modality for managing post-thoracotomy pain. Ann Thorac Cardiovasc Surg 2014; 20 (2) 113-116