Aetiology and Prognosis of Pancreatic Pseudo Cysts Over A 10 Year Period| Lupine Publishers

 Journal of Surgery| Lupine Publishers

Abstract 

Introduction

Pancreatic pseudocysts often arise as a complication of acute or chronic pancreatitis with reported prevalence in chronic pancreatitis of 20-40%. Most common cause is alcoholic chronic pancreatitis (70-78%) then idiopathic chronic pancreatitis (6-16%), then biliary pancreatitis (6-8%). The aim of this study is to assess the demographic characteristic of patients diagnosed with pseudocysts, aetiology, characteristic features, and prognosis. 

Methods

Prospective observational study to follow up patients diagnosed with pancreatic pseudocyst in 5 years (2006-2011). Data was collected in 2011 and patients followed up till June 2019. Radiology database searched for all cases that had a diagnosis confirmation by Computerised Tomography (CT). Total of 167 CT carried out for 119 patients. 35 patients were excluded due to absence of pancreatic pseudocyst after radiological re-evaluation. 

Results

In 5 years, 84 patients diagnosed with pancreatic pseudocysts on CT. 127 CT scans done mainly for follow up. 51(60.7%) males and 33 (39.3%) females; mean age= 57.8 years (20-93). 41 cases (48.8%) were associated with acute pancreatitis (8 on background of chronic pancreatitis). 21 cases (25%) were associated with chronic pancreatitis, 4 were associated with pancreatic malignancy while 18 (21.4%) were reported as incidental finding. The underlying factor was alcoholic pancreatitis in 37 patients (44%), gall stones in 19 patients (22.6%), pancreatic malignancy in 4 (4.8%) patients, biliary strictures in 2 patients and trauma in 2 patients. Idiopathic pancreatic pseudocysts were seen in 20 patients (23.8%), 18 of them were incidentally found on CT scan. 8 cases (40%) of idiopathic pseudocysts, were associated with non-pancreatic malignancies. 50% mortality (42 patients). 17 had acute pancreatitis, 15 had chronic pancreatitis, 6 were from the incidental finding and 4 from acute on top of chronic group. As for aetiology, 25 patients of the 42 had alcoholic pancreatitis, 12 had gall stones pancreatitis, 3 were unknown aetiology and 2 had pancreatic cancer. 

Conclusion

Our study showed that alcoholic pancreatitis remains the most frequent underlying aetiology for pancreatic pseudocysts although it is not as common as previously reported. Idiopathic pseudocysts constituted a substantial number of this study with a higher than expected incidental pseudocysts. The association of pancreatic pseudocysts with malignancy needs to be further evaluated.

Introduction 

Pancreatic pseudo-cysts often arise as a complication of acute or chronic pancreatitis. Previous reported prevalence of pancreatic pseudo-cysts in chronic pancreatitis ranges from 20% to 40%. Pancreatic pseudo-cysts most commonly arise in patients with alcoholic chronic pancreatitis (70% to 78%) (1, 2). The second most common cause is idiopathic chronic pancreatitis (6% to 16%), followed by biliary pancreatitis (6% to 8%) (3). Various imaging modalities are used in the diagnosis of pancreatic pseudo-cysts with Computed Tomography (CT) being the gold standard with 82% to 100% sensitivity and 98% specificity (4). There is wide variability in the range of spontaneous regression in the literature from 8 to 70%., with almost 40% of cysts that are less than 6 weeks old resolving without intervention compared to around 10% of the cysts older than 6 weeks (5). The aim of this study is to assess the demographic characteristic of diagnosed patients, aetiology of the pseudo-cysts, their characteristic features, prognosis and mortality rate 

Methods 

This is a prospective observational study to follow up all consecutive patients diagnosed with pancreatic pseudo-cyst over a period of five years (2006 – 2011) in a district general hospital. Data collected retrospectively in 2011 to identify patients with pseudopancreatic cysts. The search was conducted using the radiology database of all cases had a diagnostic confirmation of pseudo pancreatic cyst by Computerized Tomography (CT). A total number of 167 CT scans were carried out for 119 patients. Radiological re-evaluation was conducted by a designated radiologist. 35 patients were excluded from the study due to absence of pancreatic pseudo-cyst after radiological re-evaluation. The remaining 84 patients were followed up till June 2019. The following demographic data were collected (age, gender, aetiology of pancreatitis, blood tests including amylase, liver function tests, white cell count, serum calcium and oxygen saturation). Mode of treatment and related complications. Radiological characteristics of the pancreatic pseudo cyst included: site, size, duration, calcification within the cyst. Other parameters observed prospectively were; mortality/ morbidity, further episodes of pancreatitis and duration between diagnosis and mortality/ morbidity. Subgroup analysis was conducted to look at prevalence of different aetiologies in both genders. Statistical analysis was conducted using Fisher Exact test, Mann-Whitney U test and the multivariate analysis was carried out using SPSS version 25 for Windows (SPSS Inc, Chicago, IL, USA). P value ≤ .05 was considered significant. 

Results

In five years, period (2006 – 2011), 84 patients were diagnosed with pancreatic pseudo-cysts on CT scan. These patients had a total of 127 CT scans mainly for follow up. There were 51 male patients (60.7%) and 33 female patients (39.3%) with mean age of 57.8 years (20 – 93). In 41 cases (48.8%) the pseudo-cysts were associated with acute pancreatitis (8 on background of chronic pancreatitis). 21 cases (25%) were associated with chronic pancreatitis, 4 were associated with pancreatic malignancy while in 18 cases (21.4%) there was no obvious history of pancreatitis and the diagnosis was reported as incidental finding. The underlying factor was alcoholic pancreatitis in 37 patients (44%), gall stones in 19 patients (22.6%), pancreatic malignancy in 4 (4.8%) patients, biliary strictures in 2 patients and trauma in 2 patients. Idiopathic pancreatic pseudo-cysts were seen in 20 patients (23.8%), 18 of them were incidentally found on the CT scan. Of note, in 8 cases (40%) of the idiopathic pseudo-cysts, were associated with non-pancreatic malignancies. In a subgroup analysis, alcohol was the commonest aetiology in male patients 29/51 (57%) while in female patients, incidental pseudo-cysts constituted 11/33 (33.3%), P= 0.23. Gall stones were the 2nd most common aetiology in females 10/33 (30.3%). Nine patients had more than one pseudo-cyst. The size of the pseudo-cysts varied significantly in reporting from small to huge pseudo-cysts withextension into the left thigh in one case. The body of the pancreas was the most common site (33 pseudo-cysts) followed by the head of the pancreas with 28, tail 27, uncinate 4, neck 2, not specified 7, 1 junction between body and tail, 2 junction between head and body (Table 1). The majority were managed conservatively with two drained percutaneously and two drained endoscopically. The 84 patients were followed up till June 2019 (mean follow up of 10 years). This showed that 42 patients (50%) died (male: female, 21:21), mean age of 61.8 (27- 93). 9 patients (21% of the mortality) died from complications related to the pancreatitis or due to complications from the pseudo-cyst like infection or bleeding into the cyst, with one patient dying from respiratory failure following laparoscopic cholecystectomy for gall stones pancreatitis (Table 2). The 9 patients represent 10.7% cause-related mortality. 17 of those 42 patients (40%) were from the acute pancreatitis group, 15 patients (36%) from the chronic pancreatitis group, 6 patients (14%) from the incidental finding group and 4 patients (10%) from the acute on chronic group. As regards the aetiology, 25 patients of the 42 (59.5%) were from the alcoholic pancreatitis group, 12 patients (28.5%) from the gall stones pancreatitis group, 3 patients (7%) from the unknown aetiology group and 2 patients (5%) from the pancreatic cancer group, Table 2. Multivariate analysis (MANOVA) yielded a highly significant association between the aetiology of pancreatitis and death, p = 0.007; however, there was no significant association between the mode of pancreatitis (acute or chronic) and death, p = 0.338, Table 3. Using death or alive dichotomy, chi square test confirmed the highly significant relationship between the aetiology of pancreatitis and death, p = .000. A two-way analysis of variance yielded a significant relationship between the aetiology of pancreatitis and its mode of onset (acute or chronic), p = 0.000 (Table 3). The duration of time form diagnosis of pancreatitis/ pancreatic pseudo-cyst to death was quite variable ranging from 8 to 3809 days (median 1018 days) for the whole cohort of mortality patients. The range for the cause specific cohort was 10 to 1424 days (median 112 days), p-value is .04006. 12 patients (14%) had further episodes of pancreatitis requiring admission to hospital. The outcome from the follow up of the pancreatic pseudo-cysts over the study period is shown in Table 4. Table 1: Sites of the pseudo-cysts within the pancreas

*1 in junction between body and tail, 2 in junction between head and body.

Discussion

Pancreatic pseudocysts are the commonest pancreatic cystic lesions and represent 75%-80% [1]. They are localized fluid collections rich in amylase and other pancreatic enzymes that gets surround by fibrous tissue wall not lined by epithelium [2]. Pseudocysts are a common clinical problem and arise as a complication of chronic pancreatitis in up to 40% of cases [3]. Alcoholic pancreatitis is the most common cause and account for over 75% of cases in some series [4]. The incidence of pancreatic pseudocysts is low and ranges between 1.6%-4.5% irrespective of the aetiology [5,6]. The pathogenesis of pancreatic pseudocysts is the disruption to the pancreatic duct as a result of pancreatitis or trauma which results in extravasation of pancreatic secretions. Two thirds of patients with pseudocysts have demonstrable connections between the cyst and the pancreatic duct. In the other third, an inflammatory reaction most likely sealed the connection so that it is not demonstrable [7]. In acute pancreatitis, fluid collections persisting for more than 4-6 weeks that are lined by a well-defined wall of fibrous or granulation tissue, would be regarded as acute pseudocysts [2,4]. In chronic pancreatitis the mechanism is less clear, but it could be as a consequence of an acute exacerbation of the underlying disease and/or blockage of a major branch of the pancreatic duct by a protein plug, calculus or localized fibrosis [8]. The clinical presentation is quite variable and while some patients could be asymptomatic, others might present with abdominal catastrophe as a result of; bleeding, infection or rupture of the cyst [9,10]. In our study, 2 patients had acute hemorrhage into the cyst from erosion into the splenic artery while 1 patient had infection of the cyst and all 3 patients died. Various imaging modalities are used in the diagnosis of pancreatic pseudo-cysts with Computed Tomography (CT) being the gold standard with 82% to 100% sensitivity and 98% specificity [11]. Endoscopic Ultrasound (EUS) has the highest sensitivity (93% to 100%) and specificity (92% to 98%) in differentiating acute fluid collections from pancreatic abscess and other pancreatic pseudocysts [12]. In our study 41 patients (48.8%) of the pancreatic pseudocysts were associated with acute pancreatitis and 21 cases (25%) were associated with chronic pancreatitis. However, it is worth mentioning that 8 cases of the 41 in the acute pancreatitis group had a background of chronic pancreatitis. 4 patients (19%) were associated with pancreatic malignancy while 18 patients (21.4%) were incidental finding on CT scans done for other reasons. These results are different from other studies showing the prevalence of pancreatic pseudocysts in acute pancreatitis to range from 6% to 18.5% [13,14]. The prevalence of pancreatic pseudocysts in chronic pancreatitis is 20%- 40% [15]. In our study, the most common underlying factor was alcoholic pancreatitis in 37 patients (44%), gall stones in 19 patients (22.6%), pancreatic malignancy in 4 patients (4.8%), biliary strictures in 2 patients and trauma in 2 patients. Idiopathic pancreatic pseudocysts were seen in 20 patients (23.8%), 18 of them were incidentally found on the CT scan. Of note, in 8 cases (40%) of the idiopathic pseudo-cysts, were associated with non-pancreatic malignancies. Results from other series showed that pancreatic pseudocysts are most common in patients with chronic alcoholic pancreatitis (up to 78%) [16], followed by idiopathic chronic pancreatitis (6% to 16%) and biliary pancreatitis (6% to 8%) [17]. The range of spontaneous regression of pancreatic pseudocysts ranges from 8% to 70% and the two major factors affecting this are; the size of the pseudocyst and the time since diagnosis [17]. In our study, 40 patients (47.6%) had spontaneous resolution of their pseudocysts and only 4 patients had drainage procedure for their cysts (2 percutaneously and 2 endoscopically) in the initial period of the study and 1 further patient having endoscopic drainage in the follow up period of the study. The body of the pancreas was the most common site with 33 pseudo-cysts, followed by the head of the pancreas with 28, tail 27, uncinate process 4, neck 2, not specified 7, 1 in the junction between body and tail, and 2 in the junction between head and body. 9 patients in our study had multiple pseudocysts. The results in the literature about the site of pseudocysts within the pancreas is variable, as some studies showed that most pseudocysts would be in or near the tail of the pancreas [18]. In another study, most extra pancreatic pseudocysts were located in the body and tail region, whereas most intrapancreatic pseudocysts were in the head of the pancreas [19]. The overall mortality in our study was 50% (42 patients), however the cause specific mortality was only 9 patients (10.7%). 59.5% of the whole mortality cohort had alcoholic pancreatitis while 28.5% had gall stones pancreatitis. The 9 cause specific mortality patients; 7 were alcoholic pancreatitis and 2 were gall stones pancreatitis. On multivariate analysis there was a statistically significant association between the aetiology of pancreatitis and death which was also confirmed on Chi-square testing. There was no statistically significant association between the mode of pancreatitis (acute or chronic) and death. The duration of time form diagnosis of pancreatitis/ pancreatic pseudo-cyst to death was quite variable ranging from 8 to 3809 days (median 1018 days) in the whole mortality cohort. In the cause specific mortality group, the range was 10 to 1424 days (median 112 days), this was statistically significant

Conclusion

Our study showed that alcoholic pancreatitis remains the most frequent underlying aetiology for pancreatic pseudocysts although it is not as common as in other studies. The incidence of incidental pseudocysts with no history of pancreatitis is higher than that in the literature. Around 50% of pseudo pancreatic cysts in our study resolved spontaneously; therefore, conservative treatment has a big role in management of pancreatic pseudocysts. Bleeding or infection of a pseudo pancreatic cyst is an emergency associated with high mortality and should be managed promptly with laparoscopic and endoscopic approaches now gaining popularity over the surgical approach which is only used if the previously mentioned approaches fail.

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The Optimal Pain Management Methods Post Thoracic Surgery: A Literature Review| Lupine Publishers

Journal of Surgery| Lupine Publishers

Abstract

Post-operative pain control is one of the key factors that can aid in fast and safe recovery after any surgical interventions. Thoracic surgery can cause significant postoperative pain which can lead to delayed recovery, delayed hospital discharge and possibly increased risk of chest complications in the form of atelectasis and even lower respiratory infections. Therefore, appropriate pain management following thoracic surgery is mandatory to prevent development of such morbidities including chronic pain.
Keywords:Thoracic Surgery, Analgesia, VATS, Robotics, Thoracotomy

Introduction

Thoracic surgical procedures can result in severe pain which can present as a challenge to be appropriately managed postoperatively. In particular, thoracotomies are well known for their severity of pain due to the incision, manipulation of muscles and ligaments, retraction of the ribs with compression, stretching of the intercostal nerves, possible rib fractures, pleural irritation, and postoperative tube thoracotomy [1]. Recognition of this has contributed to the development of minimally invasive techniques such as video assisted thoracoscopic surgeries (VATS) and lately robotic surgery [1]. These techniques not only aim to produce better aesthetic results, but also reduce post-operative pain and enhance recovery without compromising the quality of treatment offered. Poor pain management can lead to several and serious complications such as lung atelectasis, hypostatic pneumonia due to avoidance of deep breathing in these patients as a result of pain and superimposed infection [1]. Pain management as a result, does not only lead to greater patient satisfaction, but it also reduces morbidity and mortality in patients undergoing thoracic surgery [2]. Historically, post-operative pain management for thoracic surgery involved the use of narcotics alongside parenteral or oral anti-inflammatory agents [2]. Post chest tube removal patients typically are transitioned to oral analgesia. Multiple additional pain control adjuncts were also implemented with differing levels of success [1]. Over time, intra-operative techniques have been developed which aims to target pain reduction postoperatively [2]. As our understanding of both pain management and the factors that play a role in the development of pain has increased, we have been able to target these and improve postoperative pulmonary morbidity and pain scores [1,2]. We aim to review different means of pain control in this paper in order to assess their effectiveness in achieving optimum results.

Thoracotomy

The mechanism of pain in thoracotomy involves the innervation of the intercostal, sympathetic, vagus and phrenic nerves [3]. Additionally, shoulder pain may result from stretching of the joints during the operation.
After a thoracotomy, pain can persist for two months or more, and in certain incidences it recurs after a period of cessation. The incidence of chronic pain post thoracotomy is reported to be 22-67% in the population [4]. Good surgical technique and effective acute post-operative pain treatment are evident means of preventing post-thoracotomy pain and consequent pulmonary complications [4]. Due to the multifactorial character of the pain, a multimodal approach to target pain is advised. Typically, both regional and systemic anaesthesia are administered. A combination of opioids such as fentanyl or morphine are typically used [5]. A variety of techniques for the administration of local anaesthetics are available at present, and the effectiveness of each is assessed in this paper.
a) Thoracic Epidural Analgesia (TEA)
TEA was the most widely used method of means of analgesia. It was the gold standard means of pain relief [6,7]. It is typically inserted prior to general anaesthesia, at the level of T5-T6, midway along the dermatomal distribution of the thoracotomy incision. A study by Tiippana et al. [8] measured the visual analogue scale (VAS) in order to assess the presence of pain during rest and at the time at which they coughed in 114 patients of whom 89 had TEA and 22 who had other methods of pain control. TEA was effective in alleviating pain at rest and during coughing. In TEA patients, the incidence of chronic pain of at least moderate severity was 11% and 12% at 3 and 6 months, respectively. The study found that at one week after discharge, 92% of all patients needed daily pain medication. The study advised for extended postoperative analgesia for up to the week post-discharge to be administered in order to manage this. The study however concluded overall, that TEA was effective in controlling evoked post-operative pain. However, the study did encounter problems of technical form in 24% of the epidural catheters. The incidence of chronic pain, however, was lower compared with previous studies where TEA was not used. Several other studies support that TEA is superior to less invasive methods. According to Shelley B. et al. [9] TEA was preferred by 62% of the respondents over paravertebral block (PVB) with 30% and other analgesic techniques with 8%. Limitations of this technique included hypotension and urinary retention. Certain patients with active infection and on anticoagulation are excluded from epidural placement.
b) Paravertebral Block (PVB)
PVB is considered an effective method for pain management and its use has been increased in the recent years. This technique involves injecting local anaesthetic into the paravertebral space and it is able to block unilateral multi-segmental spinal and sympathetic nerves. Previous studies have shown that it is effective in achieving analgesia and is associated with a lower incidence of side effects such as nausea, vomiting, hypotension and urinary retention [10,11]. As the lungs are collapsed, it is associated with a lower risk of pneumothorax.
In a study by Davies R.G. et al. [10] there was no significant difference in pain scores, morphine consumption and supplementary use of analgesia between TEA and PVB. The rate of failed technique was lower in PVB (OR =0.28, p=0.007). Respiratory function was improved at both 24 and 48 hours with PVB but only significantly improved at 24 hours.
c) Intercostal Nerve Block (ICNB)
ICNBs are generally administered as single injections at least two dermatomes above and below the thoracotomy incision [12]. It is performed percutaneously or under direct vision, using single injections or through placement of an intercostal catheter. It can also be formed using cryotherapy. It is associated with reduced post-operative pain scores; however, it is less effective than TEA in controlling chronic pain [12]. This was illustrated by a study by Sanjay et al. [12] which found that patients that underwent ICNB had higher pain scores 4 hours post-operatively, than those who received epidural anaesthesia using 0.25% bupivacaine (p<0.05). The study concluded that in the early post-operative period there was significant impact in pain relief for both techniques, but thereafter, epidural anaesthesia was proven to significantly reduce post thoracotomy pain over ICNB. Due to the multifactorial nature of post-thoracotomy pain, various approaches are required in order to target pain. ICNBs are useful in the blockade of intercostal nerves, whilst PVB and TEA appear to block the intercostal and sympathetic nerves. Due to the inability of regional anaesthesia to block the vagus and phrenic nerves which are implicated in the pathophysiology of pain, NSAIDs and opioids are required as adjuncts. TEA is proven to be the most effective means of treating pain alongside PVB; however, it is associated with more side effects than PVB. At present, there are a limited number of studies directly comparing pain control and post-operative outcomes between PVB and TEA. There is no conclusive evidence that either method is superior to the other regarding pain control.

Video-Assisted Thoracoscopic Surgery (VATS)

Existing evidence supports the noninferiority of thoracic PVB when compared to TEA for postoperative analgesia [13]. PVB is versatile and may be applied both unilaterally or bilaterally. It can be used to avoid contralateral sympathectomy, consequently minimising hypotension. This is an apparent advantage it has over thoracic epidural. Furthermore, it offers a more favourable side effect profile when compared to epidural anaesthesia. At present, the factors taken into consideration when selecting a regional technique include tolerance of side effects associated with TEA, consensus on best practice/technique, and operator experience [13]. A randomised controlled trial by Kosiński et al. [14] compared the analgesic efficacy of continuous thoracic epidural block and percutaneous continuous PVB in 51 patients undergoing VATS lobectomy. The primary outcome measures were postoperative static (at rest) and dynamic (coughing) visual analogue pain scores (VAS), patient-controlled morphine use and side-effect profile. The study found that pain control (VAS) was superior in the PVB group at 24 hours, both at rest (1.7 vs3.3, p=0.01) and on coughing (5.8 vs 6.6, p=0.023), and control of pain at rest was also superior in the PVB group at 36 hours (3.0 vs 3.7 (p=0.025) and at 48 hours (1.2 vs 2.0, p=0.026). There were no significant differences in the postoperative morphine requirements. In regard to side-effect profile, the study showed that the incidence of postoperative urinary retention (defined as no spontaneous micturition for 8 hours or ultrasound-assessed volume of the urinary bladder >500ml) was greater in the epidural group (64.0% vs 34.6%, p=0.0036), as was the incidence of hypotension (32.0% vs 7.7%, p=0.0031). There was no significant difference in the incidence of atelectasis (4.0% vs 7.7%, p=0.0542). However, the incidence of pneumonia was significantly more frequent in the PVB group (3.8% vs 0%, p=0/0331). Kosiński et al. concluded that PVB is as effective as thoracic epidural block in regard to pain management as it offers a superior safety profile with minimal postoperative complications. A further randomised controlled trial by Okajima et al. [15] compared the requirements for postoperative supplemental analgesia in 90 patients who received wither a PVB or thoracic epidural infusion for VATS lobectomy, segmentectomy or wedge resection. The main outcome measures were pain scores at rest (verbal rating scale 0= none and 10=maximum pain), blood pressure, side effects and overall satisfaction scores relating to pain control (1=dissatisfied and 5=satisfied). The study found a similar frequency of supplemental analgesia (50mg diclofenac sodium suppository or 15mg pentazocine intramuscularly) for moderate pain in both groups, with 56% of those in the PVB group requiring ≥2 doses, compared to 48% in the epidural group (p=0.26). Hypotension, defined as a systolic blood pressure <90mmHg, occurred more frequently in the epidural group (21.2% vs 2.8%, p=0.02). There was no difference in the incidence of pruritus (3.0% vs 0%, p=0.29) and post-operative nausea and vomiting (30.3% vs 25.0%, p=0.62) between both groups. The study found no statistical difference between patient-reported satisfaction in pain control between epidural and PVB using the verbal rating scale (5.0 vs 4.5, p=0.36). The study concluded that PVB offered additional to equivalent analgesia to epidural, a lower incidence of haemodynamic instability postoperatively. A further study by Khoshbin et al. [16] performed an analysis on 81 patients undergoing VATS for pleural aspiration +/- pleurodesis, lung biopsies or bullectomy. The main outcome was postoperative pain levels, documented every 6 hours and scored against the Visual analogue Scale (0= no pain, 10= worst possible pain). In both PVB and epidural groups, bupivacaine 0.125% was the local anaesthetic of choice, with clonidine added to the epidural infusion at 300μg in 500ml. The study showed that there was no significant difference in mean pain scores between PVB or EP (2.1 vs 2.9, p=0.899), therefore concluding that PVB is as effective as epidural in controlling pain post-VATS.

Robotic Lung Surgery

Minimally invasive techniques are considered advantageous over open surgical approaches due to their shorter recovery times, reduced perceived levels of pain post-operatively and shorter postoperative length of stay in hospital [17-19]. Robotic surgery has become a popular method in recent years. Debate remains regarding whether robotic surgery is superior to VATS in regard with pain reduction. A case control study by Louie et al. [19] compared 45 robotic assisted lobectomies (RAL) to 34 VATS lobectomies. The study showed that both groups had a similar mean ICU stay (0.9 vs 0.6 days) and a mean total length of stay (4.0 vs 4.5 days). The study showed that patients that underwent robotic lobectomies had a shorter duration of analgesic use post-operatively (p=0.039) and a shorter time resuming to normal everyday activities (p=0.001). A limitation in this study was an inaccurate record of the amount of pain relief used by the patients, ultimately working as a confounding factor when interpreting the results. In a separate study by Jang et al. [18] 40 patients undergoing RAL were compared retrospectively to 80 VATS patients (40 initial patients and 40 most recent patients), all with resectable non-small cell lung cancer. The study showed that the post-operative median length of stay was significantly shorter in RAL patients compared to the initial VATS patients. The rate of post-operative complications was significantly lower in the RAL group (10%) compared to the initial VATS group (32.5%) and similar to the recent VATS group (17.5%). Post-operative recovery was easier for patients in both the RAL and VATS group due to earlier mobilisation, allowing them to return to their everyday activities quicker. In a retrospective review by Kwon et al. [17] 74 patients undergoing robotic surgery, 227 patients undergoing VATS and 201 patients undergoing anatomical pulmonary resection were assessed and compared with regard to acute (visual pain score) and chronic pain (Pain DETECT questionnaire). The study showed that there was no significant difference in acute or chronic pain between patients undergoing robotic assisted surgery and VATS. Despite no significant difference in pain scores, 69.2% of patients who underwent robotic-assisted surgery felt the approach affected their pain versus 44.2% of the patients who underwent VATS (p=0.0330). These results all support the superiority of robotic surgery over VATS and open approaches with regard to pain, length of hospital stay and recovery times. Both robotic surgery and VATS have their benefits i.e. two-versus three-dimensional view, instrument manoeuvrability, and reduced post-operative pain.

Conclusion

Since post-thoracotomy pain is multifactorial, a multimodal approach is required. In particular, ICNB blocks the intercostal nerves, and PVB and TEA appear to block the intercostal and sympathetic nerves. NSAIDs and opioids are required as valgus and phrenic nerve cannot be blocked by regional anaesthesia. TEA is evident to be the most effective in treating pain alongside with PVB. It is however associated with more side effects than PVB.


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