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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 4  |  Page : 418-423

Bilateral superficial cervical plexus block for transoral endoscopic thyroidectomy (vestibular approach): a randomized controlled study


Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University, Oncology Center, Egypt

Date of Submission30-May-2019
Date of Acceptance14-Jul-2019
Date of Web Publication06-Jan-2020

Correspondence Address:
MD Alaa El-Deeb
Department of Anesthesia, Mansoura University, Mansoura, 35514
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_45_19

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  Abstract 

Background Transoral endoscopic thyroidectomy is one of the scarless approaches for thyroid surgery. The aim of this study was to assess analgesic efficacy of cervical plexus block after general anesthesia for transoral thyroidectomy. The secondary goals are hospital stay, total analgesic consumption, and adverse effects of either anesthesia or surgery.
Patients and methods This study was carried out in Mansoura Oncology Hospital. After informed consent, patients undergoing transoral thyroidectomy were randomized into two groups: the first group received general anesthesia (group G) and the second group received bilateral superficial cervical plexus block with ropivacaine 0.5% after induction of general anesthesia (group GB). Analgesic efficiency was our primary concern. Secondary outcomes included patient satisfaction, hospital stay, rescue analgesic, and adverse effects.
Results After applying the exclusion criteria, 40 patients were randomized into two groups in this study. The postanesthesia care unit time, pain score for 8 h postoperatively, postoperative opioid requirement, and hospital stay were statistically significantly less in group GB than in the control group. Patient satisfaction is more observed in group GB.
Conclusion Bilateral superficial cervical plexus block provided effective analgesia after transoral endoscopic thyroidectomy. Moreover, it results in more patient satisfaction and less hospital stay.

Keywords: analgesia, superficial cervical plexus block, transoral endoscopic thyroidectomy


How to cite this article:
El Motlb EA, El-Deeb A. Bilateral superficial cervical plexus block for transoral endoscopic thyroidectomy (vestibular approach): a randomized controlled study. Res Opin Anesth Intensive Care 2019;6:418-23

How to cite this URL:
El Motlb EA, El-Deeb A. Bilateral superficial cervical plexus block for transoral endoscopic thyroidectomy (vestibular approach): a randomized controlled study. Res Opin Anesth Intensive Care [serial online] 2019 [cited 2020 Jan 29];6:418-23. Available from: http://www.roaic.eg.net/text.asp?2019/6/4/418/275139


  Introduction Top


Neck surgeries, including thyroid surgery, are some of the most common surgical procedures [1]. Primary access to the thyroid gland has been through the transcervical approach since its description in late 1880s by Kocher [2]. Conventional open thyroidectomy is often associated with postoperative complications including nerve damage, voice disturbances, paresthesia, adhesions, and prominent scarring. Natural orifice transluminal endoscopic surgery (NOTES) is a promising approach which leaves no scar, produces few complications, and affords faster discharge from care [3],[4]. Cosmetic advantages and minimally invasion become of great values for patients undergoing thyroidectomy [5]. However, trans-oral endoscopic thyroidectomy couldn’t considered as minimal invasive because of wide flap dissection and scare at the incision site. Scarless approaches to the thyroid surgery include transoral robotic or endoscopic thyroidectomy vestibular approach [6]. Relative contraindications to transoral endoscopic thyroidectomy include smoking and oral pathology [6].

Bilateral superficial cervical plexus block ((BSCPB) has been used in combination with general anesthesia in open thyroid surgery to reduce general anesthetics and shorten the hospital stay. Moreover, it significantly decreased the severity of neck pain during the first postoperative day [7],[8]. To the best of our knowledge, BSCPB has not been tried before in transoral endoscopic thyroidectomy. The aim of this study was to assess analgesic efficacy of superficial cervical plexus block in transoral endoscopic thyroidectomy. The primary outcome was the visual analogue score. The secondary goals were PACU (post anesthesia care unit) time, hospital stay, total analgesic consumption, and adverse effects.


  Patients and methods Top


After getting approval from Mansoura Faculty of Medicine Institutional Research Board (MFM-IRB, http://irb.mans.edu.eg, Code: R1.18.07.225.) and registration in UMIN-CTR (University Hospital Medical Information Network Clinical Trials Registry, https://umin.ac.jp, with ID UMIN000034322), this study was carried out in Mansoura Oncology Hospital.

Patients scheduled for thyroid surgeries (transoral endoscopic vestibular approach) were those who had ASA (physical status) I, II, or III, with the gland measuring less than ten centimeters in ultrasound and less than 45 ml, or dominant nodule of papillary microcarcinoma without metastases either local or distant. Patients with previous neck surgery or recurrent goiter, gland more than 45 ml or distant metastases, tracheal/esophageal infiltration, hyperthyroidism, mediastinal goiter, and poorly or undifferentiated cancer were excluded.

After informed consent, patients undergoing thyroidectomy were randomized into two groups: the first group received general anesthesia (group G) and the second group received bilateral cervical plexus block after induction of general anesthesia (group GB). Randomization was done using computer-generated randomization list.

After arrival to the operating room, through the peripheral intravenous line, an infusion was started with normal saline. In group G, intravenous propofol (2.5 mg/kg), and fentanyl (2 μg/kg) were used to induce general anesthesia. Cisatracurium 0.15 mg/kg was used to facilitate tracheal intubation through nasal route. Then, anesthesia was maintained with 2.5% sevoflurane and 50% oxygen in 50% air. Ventilation was mechanically controlled and adjusted to keep an end-tidal concentration of carbon dioxide 30–40 mmHg throughout surgery. While in group GB, after the induction of general anesthesia, BSCPB was performed by an anesthesiologist guided by SonoSite portable ultrasound unit (SonoSite, Bothell, Washington, USA). The site of needle insertion for block was the midpoint of the lateral border of the sternocleidomastoid muscle. Thereafter, five millilitres of ropivacaine 0.5% was given on either side . Pain was assessed by personnel blinded to the procedure. Intraoperative monitoring includes ECG, heart rate, pulse oximetry, noninvasive blood pressure, and end-tidal carbon dioxide concentration.

At the end of surgery, the residual paralysis was reversed by atropine (0.02 mg/kg) and neostigmine (0.04 mg/kg). Visual analog scale was the tool to assess the postoperative pain [9] (in which 0 cm=no pain and 10 cm=the worst pain imaginable) every 15 min in the postanesthesia care unit (PACU), and then at 2, 4, 6, 12, and 24 h postoperatively. Then patient-controlled analgesia pump was programmed to deliver fentanyl 25 μg/ml fentanyl, bolus 1–2 ml, lockout interval 5–10 min, max 20 ml/4 h, and no background infusion. Patient satisfaction about anesthesia was assessed (numeric rating scale of 1–100 NRS for satisfaction: 100=very satisfied to 1=totally dissatisfied.)

An antiemetic ‘rescue’ drug is 4 mg ondansetron intravenously. Patients were discharged from the PACU according to the Aldrete discharge criteria [10].

Sample size

The sample size was based on the assumption that the pain score in the group received cervical plexus block will be similar to similar to those in previously published data(7,8). A total of 20 children were required per group to detect a difference of 20% in VAS scale pain scores with a power of 80%, using the following formula:





δ, expected difference to be detected between the sample and population.

α, level of acceptability of a false positive result (level of significance=0.05).

β, level of acceptability of a false negative result (0.20).

1−β, power (0.80).

Statistical analysis

Data were analyzed using the Statistical Package of Social Science (SPSS, SPSS Inc., Chicago, Illinois, USA) program for Windows (standard version 21). The normality of the data was first tested with one-sample Kolmogorov–Smirnov test. The two groups were compared with Student t test (parametric data) and Mann–Whitney test (nonparametric data).

The threshold of significance is fixed at 5% level (P value). The results were considered significant when the probability of error is less than 5% (P≤0.05). The smaller the P value obtained, the more significant the results.


  Results Top


A total of 51 patients, admitted for thyroid surgeries, were assessed for eligibility; of them, 40 patients were included in this study after applying the exclusion criteria. Eleven patients were excluded because of obstructive pulmonary disease, cancer thyroid with metastases, multinodular goiter with retrosternal extension, and patient’s refusal ([Figure 1]).
Figure 1 Study flowchart.

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The patients showed no statistically significant difference with respect to age, sex, weight, duration of surgery, and type of surgery ([Table 1]). The PACU time and postoperative opioid requirement were statistically significant less in GB group than in the control group ([Table 2]). Moreover, significantly longer time elapsed before first request of postoperative analgesia in group GB than in control group ([Table 2]). Moreover, mean pain scores were statistically significantly less in GB group than in the control groups for 8 h postoperatively ([Figure 2]).
Table 1 Patients’ characteristics, duration, and primary diagnosis

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Table 2 Postoperative data

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Figure 2 Postoperative visual analog scale.

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Group GB showed more significant patient satisfaction when compared with the other group ([Figure 3]). The hospital stay is statistically significantly shorter in group GB. Incidence of adverse effects related to either surgery or anesthesia was comparable in the two groups ([Table 2]).
Figure 3 Patient satisfaction scale.

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  Discussion Top


Surgical advances have led to the development of NOTES, which results in a scarless surgery [10],[11]. Transoral endoscopic thyroid surgery is a minimally invasive approach that provides a hidden incision in the oral cavity without extensive tissue dissection [12]. Transoral thyroidectomy (a kind of NOTES) is safe and feasible in well-selected patients and offers good perioperative and postoperative outcomes [13]. It could be a safe method in the hand of experienced surgeons [5].

Ultrasound-guided BSCPB was effective at reducing postoperative pain and opioid consumption in patients undergoing conventional open thyroid surgeries [14],[15],[16],[17]. The literature suggests that BSCPB has similar results to combined superficial and deep cervical plexus block [18]. It is safer than combined blocks and may be more appropriate for clinical application [19].

This study showed that BSCPB with GA for transoral endoscopic thyroidectomy resulted in shorter PACU time and effective postoperative analgesia in terms of less opioid requirement, longer time elapsed before first request of analgesia, and better mean pain scores for 8 h.

In accordance with these results, Shih et al. [7] studied the effect of BSCPB with general anesthesia for open thyroidectomy. They found that it reduces general anesthetics required and significantly lowers the severity of neck pain during the first postoperative day [7].

Moreover, in a meta-analysis of randomized controlled trials, Warschkow et al. [20] concluded a significant benefit with combination of BSCPB and general anesthesia in reducing pain 6 and 24 h after conventional open thyroidectomy. Similar results were reported by Karthikeyan et al. [17], Andrieu et al. [21], and Kannan et al. [22].

In contrast to our results, Herbland et al. [23] concluded no improvement in the postoperative analgesia with BSCPB before or after conventional open thyroidectomy. The exact reason for such conflict is difficult to explain.

Our study reported more significant patient satisfactions and shorter hospital stay in group GB compared with group G. Similar results were reported with use of combined GA and BSCPB in conventional open thyroidectomy [7].

This study showed no adverse effects related to BSCPB. This is in contrast to a meta-analysis by Warschkow et al. [20] that revealed adverse events in three patients who had transient paresis of the brachial plexus in two cases and a diaphragmatic paresis in one case. An explanation for this might be owing to the use of ultrasound-guided technique in our study.

One of limitation to this study is inability to compare its results with similar studies. BSCPB has been performed many times for conventional open thyroidectomy but not for transoral endoscopic thyroidectomy.


  Conclusion Top


BSCPB provided effective analgesic after transoral endoscopic thyroidectomy. Moreover, it results in more patient satisfaction and less hospital stay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Sun GH, DeMonner S, Davis MM. Epidemiological and economic trends in inpatient and outpatient thyroidectomy in the United States, 1996–2006. Thyroid 2013; 23:727–733.  Back to cited text no. 1
    
2.
Adam MA, Speicher P, Pura J, Dinan MA, Reed SD, Roman SA et al. Robotic thyroidectomy for cancer in the US: patterns of use and short-term outcomes. Ann Surg Oncol 2014; 21:3859–3864.  Back to cited text no. 2
    
3.
Sivakumar T, Amizhthu RA. Transoral endoscopic total thyroidectomy vestibular approach: a case series and literature review. J Minim Access Surg 2018; 14:118–123.  Back to cited text no. 3
    
4.
Dionigi G, Chai YJ, Tufano RP, Anuwong A, Kim HY. Transoral endoscopic thyroidectomy via a vestibular approach: why and how? Endocrine 2018; 59:275–279.  Back to cited text no. 4
    
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Witzel K, Benhidjeb T, Kaminski C, Messenbaeck FG, Weitzendorfer M. Hybrid techniques and patients’ safety in implementing transoral sublingual thyroidectomy. Endocrine 2018; 60:50–55.  Back to cited text no. 5
    
6.
Razavi CR, Russell JO. Indications and contraindications to transoral thyroidectomy. Ann Thyroid 2017; 2:12.  Back to cited text no. 6
    
7.
Shih ML, Duh QY, Hsieh CB, Liu YC, Lu CH, Wong CS et al. Bilateral superficial cervical plexus block combined with general anesthesia administered in thyroid operations. World J Surg 2010; 34:2338–2343.  Back to cited text no. 7
    
8.
Steffen T, Warschkow R, Brändle M, Tarantino I, Clerici T. Randomized controlled trial of bilateral superficial cervical plexus block versus placebo in thyroid surgery. Br J Surg 2010; 97:1000–1006.  Back to cited text no. 8
    
9.
Dolin SJ, Cashman JN, Bland JM. Effectiveness of acute postoperative pain management: I.Evidence from published data. Br J Anaesth 2002; 89:409–423.  Back to cited text no. 9
    
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Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995; 7:89–91.  Back to cited text no. 10
    
11.
Patel RD, Gowani N, Nadkarni M, Rege S, Devalkar P. Anaesthetic management in transoral endoscopic thyroidectomy. J Clin Diagn Res 2017; 11:7–8.  Back to cited text no. 11
    
12.
Karakas E, Anuwong A, Ketwong K, Kounnamas A, Schopf S, Klein G. Transoral thyroid and parathyroid surgery: Implementation and evaluation of the transoral endoscopic technique via the vestibular approach (TOETVA). Chirurg 2018; 89:537–544.  Back to cited text no. 12
    
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Clark JH, Kim HY, Richmon JD. Transoral robotic thyroid surgery. Gland Surg 2015; 4:429–434.  Back to cited text no. 13
    
14.
Shan L, Liu J. A systemic review of transoral thyroidectomy. Surg Laparosc Endosc Percutan Tech 2018; 28:135–138.  Back to cited text no. 14
    
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Santosh BS, Mehandale SG. Does dexmedetomidine improve analgesia of superficial cervical plexus block for thyroid surgery? Indian J Anaesth 2016; 60:34–38.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Ahiskalioglu A, Yayik AM, Oral Ahiskalioglu E, Dostbil A, Doymus O, Karadeniz E et al. Ultrasound-guided bilateral superficial cervical block and preemptive single-dose oral tizanidine for post-thyroidectomy pain: a randomized-controlled double-blind study. J Anesth 2018; 32:219–226.  Back to cited text no. 16
    
17.
Karthikeyan VS, Sistla SC, Badhe AS, Mahalakshmy T, Rajkumar N, Ali SM et al. Randomized controlled trial on the efficacy of bilateral superficial cervical plexus block in thyroidectomy. Pain Pract 2013; 13:539–546.  Back to cited text no. 17
    
18.
Ivanec Z, Mazul-Sunkol B, Lovricević I, Sonicki Z, Gvozdenović A, Klican K et al. Superficial versus combined (deep and superficial) cervical plexus block for carotid endarterectomy. Acta Clin Croat 2008; 47:81–86.  Back to cited text no. 18
    
19.
Su Y, Zhang Z, Zhang Q, Zhang Y, Liu Z. Analgesic efficacy of bilateral superficial and deep cervical plexus block in patients with secondary hyperparathyroidism due to chronic renal failure. Ann Surg Treat Res 2015; 89:325–329.  Back to cited text no. 19
    
20.
Warschkow R, Tarantino I, Jensen K, Beutner U, Clerici T, Schmied BM et al. Bilateral superficial cervical plexus block in combination with general anesthesia has a low efficacy in thyroid surgery: a meta-analysis of randomized controlled trials. Thyroid 2012; 22:44–52.  Back to cited text no. 20
    
21.
Andrieu G, Amrouni H, Robin E, Carnaille B, Wattier JM, Pattou F et al. Analgesic efficacy of bilateral superficial cervical plexus block administered before thyroid surgery under general anaesthesia. Br J Anaesth 2007; 99:561–566.  Back to cited text no. 21
    
22.
Kannan S, Surhonne NS, Chethan Kumar R, Kavitha B, Devika Rani D, Raghavendra Rao RS. Effects of bilateral superficial cervical plexus block on sevoflurane consumption during thyroidsurgery under entropy-guided general anesthesia: a prospective randomized study. Korean J Anesthesiol 2018; 71:141–148.  Back to cited text no. 22
    
23.
Herbland A, Cantini O, Reynier P, Valat P, Jougon J, Arimone Y et al. The bilateral superficial cervical plexus block with 0.75% ropivacaine administered before or after surgery does not prevent postoperative pain after total thyroidectomy. Reg Anesth Pain Med 2006; 31:34–39.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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