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Serratus anterior plane block for hybrid transthoracic esophagectomy: a pilot study

Authors Barbera C, Milito P, Punturieri M, Asti E, Bonavina L

Received 3 September 2016

Accepted for publication 24 November 2016

Published 4 January 2017 Volume 2017:10 Pages 73—77


Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Colin Mak

Peer reviewer comments 2

Editor who approved publication: Dr Michael Schatman

Cinzia Barbera,1 Pamela Milito,2 Michele Punturieri,1 Emanuele Asti,2 Luigi Bonavina2

1Anesthesiology Unit, 2Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy

Background: Pain is a major limiting factor in patient’s recovery from major thoracic surgical procedures. Thoracic epidural analgesia (TEA), the current gold standard of perioperative management, has contraindications, can technically fail, and carries a risk of complications such as epidural abscess and spinal hematoma. The ultrasound-guided serratus anterior plane (SAP) block is a promising regional analgesia technique.
Objectives: Since the anatomic space involved in the SAP block corresponds to the area exposed by the surgeon during right posterolateral thoracotomy, we investigated the feasibility of a “surgically guided” continuous SAP block as an alternative to TEA in selected esophagectomy patients.
Study design: This was a pilot case-series study.
Setting: This study was carried out in a tertiary-care university hospital.
Methods: The demographic and clinical data of patients in whom the continuous SAP block was performed were retrieved from a prospectively maintained database of hybrid (laparoscopy plus right thoracotomy) Ivor Lewis esophagectomy. The SAP block was performed upon closure of the thoracotomy incision using a 19-gauge catheter tunnelized subcutaneously and positioned in the deep plane between the serratus anterior muscle and the ribs. A bolus dose of 30 mL of levobupivacaine 0.25% was injected, followed by a continuous infusion of the 0.125% solution at 7 mL/h until postoperative day 4.
Results: Between January 2016 and July 2016, seven (20%) out of 37 esophagectomy patients underwent a SAP block rather than TEA for the following reasons: inability to insert the epidural catheter, antiaggregation or anticoagulant therapy, or unplanned thoracotomy. The procedure was uneventful in all patients. Only two patients required rescue analgesia on day 1.
Conclusion: Continuous SAP block under direct vision is feasible and safe. This novel “surgically guided” application of the SAP block may be useful in case of failure or contraindications to TEA.

Keywords: serratus anterior block, thoracic epidural anesthesia, post-thoracotomy pain, esophageal carcinoma, transthoracic esophagectomy

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