title: Serratus anterior plane block for hybrid transthoracic esophagectomy: a pilot study.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  This was a pilot case-series study.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Anesthesiology Unit.
authors.forename: Cinzia
authors.initials: C
authors.lastname: Barbera
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy.
authors.forename: Pamela
authors.initials: P
authors.lastname: Milito
authors.affiliation: Anesthesiology Unit.
authors.forename: Michele
authors.initials: M
authors.lastname: Punturieri
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Asti
authors.affiliation: Department of General Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Milano, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Bonavina
keywords: esophageal carcinoma; post-thoracotomy pain; serratus anterior block; thoracic epidural anesthesia; transthoracic esophagectomy