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Year : 2018  |  Volume : 12  |  Issue : 2  |  Page : 417-422  

Comparison of intrapleural with paravertebral levobupivacaine analgesia for thoracoscopic sympathectomy: A randomized controlled study

1 Department of Anaesthesia, Mansoura University, Mansoura, Egypt
2 Department of Surgery, Mansoura University, Mansoura, Egypt

Date of Web Publication14-Jun-2018

Correspondence Address:
Dr. Alaa El-Deeb
Department of Anaesthesia, Mansoura University, Mansoura
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aer.AER_32_18

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Background: Palmar hyperhidrosis is a benign disease of excessive sweating in the palm that exceeds the physiological state. Thoracoscopic sympathectomy is an effective surgical treatment for localized hyperhidrosis. Aims: The aim of this study was to compare paravertebral block (PVB) with intrapleural analgesia in thoracoscopic sympathectomy. Settings and Design: A total of 90 patients physical status American Society of Anesthesiologists Classes I or II scheduled for arthroscopic thoracoscopic sympathectomy were enrolled in this study. Subjects and Methods: Patients were randomly allocated into three groups; in the controlled (C) group, no regional block was performed. In the intrapleural (I) group or paravertebral (P) group using a volume of 20 ml of levobupivacaine 0.5%. The first request for analgesia postoperatively was our primary concern. Secondary outcomes included pain scores, the cumulative consumption of fentanyl during the 1st postoperative day, pulmonary functions, blood gases, and complications. Statistical Analysis Used: Statistical analysis was done using Statistical Package for Social Sciences (SPSS 19.0, Chicago, IL, USA). Results: First request of analgesia in paravertebral group was statistically significantly longer when compared with either control or intrapleural group. In addition, total fentanyl dose was significantly higher in control group when compared with the other groups. Groups I and P showed statistically significant less pain scores, better pulmonary function, and blood gases when compared with control group. Conclusion: We concluded that either intrapleural or paravertebral analgesia compared with control group in thoracoscopic sympathectomy resulted in later request of analgesia, improved pain control, reduced analgesic requirements postoperatively, preservation of lung function and acid-base balance. The PVB, compared to intrapleural, had an advantage of longer and effective analgesia.

Keywords: Intrapleural, paravertebral, thoracoscopic sympathectomy

How to cite this article:
Elbahrawy K, El-Deeb A, Diab DG, Regal S. Comparison of intrapleural with paravertebral levobupivacaine analgesia for thoracoscopic sympathectomy: A randomized controlled study. Anesth Essays Res 2018;12:417-22

How to cite this URL:
Elbahrawy K, El-Deeb A, Diab DG, Regal S. Comparison of intrapleural with paravertebral levobupivacaine analgesia for thoracoscopic sympathectomy: A randomized controlled study. Anesth Essays Res [serial online] 2018 [cited 2020 Apr 7];12:417-22. Available from:

   Introduction Top

Palmar hyperhidrosis is excessive sweating in the palm that exceeds the physiological state. It is a benign disease with unknown cause.[1] The reason for hyperhidrosis is disrupted sympathetic stimulation. It occurs in general population with an incidence of 1%; however, it disturbs the patient's life and activities.[2]

Thoracoscopic sympathectomy is an effective surgical treatment for localized hyperhidrosis. Response to treatment is rapid and fast. Thoracoscopy helps surgeon to locate and to divide specific parts of the thoracic sympathetic chain in a considerable time with no harm.[3]

Although thoracoscopic sympathectomy is rapid and simple technique with rare complications, it is associated with severe pain in the postoperative period.[4],[5] Such pain make breathing and coughing difficult resulting in increased occurrence of pulmonary complications, need for analgesic, and hospital stay.[6]

Intrapleural analgesia (IP) is a technique of injecting local anesthetic into the pleural cavity for sake of prolonged analgesia with no complications. Complications include but not limited to pneumothorax and intravascular injection of local anesthetic.[7] IP has a rapid onset, but duration might be insufficient. The area covered by analgesia includes the thorax and the upper part of the abdomen. No hemodynamic adverse effects occur and ventilatory function is rather improved. The main mechanism of analgesia is probably a retrograde intercostal nerve blockade.[8]

Paravertebral block (PVB) is well-established old technique of injecting local anesthetic in the paravertebral space either in the abdomen or chest. The use of ultrasound makes it is safe and effective in different types of surgery as well as pain management.[9],[10],[11] The safety of thoracic paravertebral block (TPVB) has been proven. It has a comparable rate of complications to thoracic epidurals and intercostal blockade.[12] To the best of our knowledge, intrapleural was not compared with paravertebral levobupivacaine analgesia in patients submitted for thoracoscopic sympathectomy. In this study, we compared both techniques and found out their effects on postoperative pain, respiratory function, and blood gases.

   Subjects and Methods Top

Following Institutional Research Board approval, 90 patients aged 25–45 years physical status American Society of Anesthesiologists Classes I or II scheduled for elective thoracoscopic sympathectomy under general anesthesia at Main University Hospital, was included in this controlled randomized prospective blind study after obtaining informed written consent.

Patients with a history of cardiopulmonary, renal, hepatic, neuropsychiatric, and endocrinal diseases, seizures, hypertension, drug dependence, or those receiving antipsychotic, anticonvulsants, opioids, or other analgesics during the last 7 days were excluded from that study.

Preoperative blood gases and pulmonary function tests were conducted for all patients. The studied patients were randomized into three groups (30 patients each) using computer-generated randomization codes included in sealed closed, opaque envelopes. In the controlled (C) group, no regional block was performed. The Intrapleural (I) group or paravertebral (P) group used a volume of 20 ml of levobupivacaine 0.5%. All operative room staff was unaware of the patient randomization code.

All patients were familiarized with a 10 cm visual analog scale (VAS) (0 = no pain; 10 = worst imaginable pain) to assess the intensity of pain. Anesthesia technique was standardized in all patients. Patient's monitoring included noninvasive blood pressure, electrocardiography, and pulse oximetry. Before induction of anesthesia, 10 ml/kg of lactated Ringer's solution was infused. General anesthesia was induced with propofol in a dose of 2.5 mg/kg, and fentanyl 1–2 μg/kg. Rocuronium 0.6 mg/kg was given to facilitate tracheal intubation. Anesthesia was maintained with sevoflurane and oxygen/air. Patient's lungs were ventilated using volume-controlled ventilation with decreased tidal volume and increased respiratory rate for ease of surgeon work. Permissible hypercarbia was allowed.

Surgical relaxation was maintained with rocuronium 0.1 mg/kg increments. At the end of surgery, sevoflurane was discontinued and reversal of residual neuromuscular blockade before extubation.

In paravertebral group, PVB is performed at the end of operation before recovery while patient in the left lateral position under complete aseptic condition. The ultrasound probe was placed perpendicular to the midline at level of 8th rib close to the spinous process. The probe was then moved in a caudal direction to visualize the movement of the visceral and parietal pleura over each other during positive pressure ventilation. Rotation of the probe followed by tilting, allowed the intercostal muscles to be identified. A 22G needle was then inserted inplane at the lateral end of the probe. The needle was gradually advanced until it reached the space between the internal and innermost intercostal muscles. After identification of the space between the muscles and confirmation of negative blood and air on aspiration test, 20 ml of 0.5% levobupivacaine was injected. Spread of local anesthetic could be visualized together with depression of the pleura.[12]

In intrapleural group, the local anesthetic, L bupivacaine was injected bilaterally (0.5%–20% ml) directly through the port of the endoscopic sympathectomy at the end of the surgery.

A standard postoperative analgesic regimen; fentanyl patients controlled analgesia solution contained fentanyl 10 μg/ml. The pump device was programmed to deliver 20 μg of fentanyl as bolus with 12 min lockout time, a maximum dose of 100 μg/h and no basal rate infusion.

If the patient had persistent postoperative nausea and/or vomiting, ondansetron 4 mg was administered intravenously.

A blinded investigator to the patient's randomization recorded the primary outcome which is the first request for analgesia postoperatively.

Secondary outcomes included VAS pain scores at rest were recorded at the 2, 4, 6, and 12 h after surgery and the cumulative consumption of fentanyl during the first 24 postoperative-h. Postoperative complications such as vomiting, delayed awakening, hallucination, nightmares, insomnia, diplopia, nystagmus, tachycardia, hypertension, seizures, or tremors were recorded.

Blood gases at the (2, 4, 6, 12, and 24 h) and pulmonary function tests at the (6, 12, and 24 h) were conducted for all patients postoperatively. Pulmonary function tests were done using PC card spirometer, manufactured by medical Graphico Corporation (St. Paul, MN 55127 USA), according to American thoracic society recommendation. Best of three maneuvers was chosen. For the trial to be accepted, it should have good start, smooth continuous curve, and good finish.

Sample size was calculated based on pilot study with our primary concern, first request for analgesia postoperatively, and setting alpha to 0.05, we need minimally 25 cases in each group to detect 15% difference with 80% power. We increased the sample to 30 cases to compensate for possible dropouts.

Statistical analysis

SPSS version 19 (SPSS, Chicago, IL, USA) was used to analyze data after testing normality of the data was first tested with one-sample Kolmogorov–Smirnov test. Qualitative data were described using number and percent. Association between categorical variables was tested using Chi-square test or Fischer exact test. Continuous variables were presented as mean ± standard deviation. The two groups were compared with Student's t-test and paired groups with paired t-test. For all above mentioned statistical tests done, the threshold of significance is fixed at 5% level (P value). The smaller the P value obtained, the more significant are the results. The results were considered; nonsignificant when the probability of error is more than 5% (P > 0.05), significant when the probability of error is <5% (P ≤ 0.05) and highly significant when the probability of error is <0.1% (P ≤ 0.001).

   Results Top

A total of 39 patients, submitted for elective thoracoscopic sympathectomy under general anesthesia, were assessed for eligibility. Three patients were excluded because of receiving anticonvulsants and cardiac problems. Ninety patients were randomized into three groups [Figure 1].
Figure 1: Study flowchart

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Demographic data of patients and duration of surgery did not differ among groups [Table 1].
Table 1: Demographic data of patients and duration of surgery

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First request of analgesia in paravertebral group was statistically significant longer when compared with either control or intrapleural group. Total fentanyl dose was significantly lower in I andPgroups when compared with control group. Incidence of vomiting in control group was high when compared to I andPgroups [Table 2] and [Figure 2].
Table 2: Intraoperative and postoperative variables

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Figure 2: First request of analgesia

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Groups I andPshowed statistically significant less pain scores when compared with control group at 2, 4, 6 h postoperatively [Figure 3].
Figure 3: Pain score

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Blood gases in control group showed statistically significant less potential of hydrogen and arterial partial pressure of oxygen along with higher arterial partial pressure of carbon dioxide when compared with I andPGroups at 2, 4, and 6 h postoperatively [Table 3].
Table 3: Perioperative arterial blood gases

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In the control group, there was a significant decrease in forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) when compared with paravertebral and intrapleural groups at 6 and 12 h postoperatively. There were no significant differences in FEV1/FVC ratio among groups [Table 4].
Table 4: Pulmonary functions tests

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   Discussion Top

Endoscopic thoracic sympathectomy for hyperhidrosis is considered as a lifestyle procedure that solves the patients' problems in a rapid and effective manner. Although the risks associated with such technique are low in incidence, they may be potentially dangerous.[13]

In this study, we compared IP and PVB in patients submitted for thoracoscopic sympathectomy. The cumulative consumption of fentanyl during the first 24 postoperative-h was significantly less in paravertebral and intrapleural groups compared with control group. Furthermore, Groups I andPshowed statistically significant less pain scores when compared with control group in first 6 h postoperatively.

In accordance with these results, Silva et al.[6] reported improved pain management and decreased analgesic consumption with intrapleural block when compared to intravenous analgesia. In addition, observation of decreased pain score and opioid use in response to pain, by Assalia et al.,[7] in patients underwent thoracoscopic sympathectomy under general anesthesia with bilateral intrapleural bupivacaine analgesia. Lieou et al.[14] documented a similar result in the early postoperative hours after thoracoscopic sympathectomy with intrapleural bupivacaine.

El-Dawlty et al.[15] randomly allocated 40 patients scheduled to thoracic sympathectomy into four groups; intramuscular pethidine or ketoprofen or combination of intrapleural bupivacaine with either drug. They concluded that combination of intrapleural bupivacaine and intramuscular ketoprofen resulted in more better analgesia and less consumption of rescue morphine postoperatively when compared to each modality alone.

Our study showed that patients in paravertebral group consume less fentanyl during 1st postoperative day and request analgesic earlier compared with those in intrapleural group. No serious complication was associated with PVB. In addition, a restrictive pattern of pulmonary function and compensated respiratory acidosis was noticed in control group compared with treatment groups.

PVB is observed by Piraccini et al.[16] to be more effective as analgesic and less deterioration of lung function in the postoperative period. They consider PVB and thoracic epidural analgesia to have similar results regarding these two issues with a better safety profile with paravertebral.

A randomized study by Esme et al.[17] on patients underwent lung resection, reported reduced postoperative pain scores, length of hospital stays, pulmonary complications, and preserved postoperative FEV1 with paravertebral morphine analgesia when compared to intravenous tramadol plus metamizol.

Xu et al.[18] assessed the anesthetic effect and safety of ultrasound-guided TPV blockade in video-assisted thoracoscopic sympathectomy for the treatment of palmar hyperhidrosis. They concluded that ultrasound-guided TPV blockade is safe, effective, and is associated with less complications and better postoperative recovery in those type of patients.

Moreover, Fujii et al.[19] observed that thoracic PVB (TPVB) is an efficient alternative to epidural anesthesia. They assumed that the local anesthetic acted most strongly at the intercostal level of the injection.

Kundra et al.[20] reported well-preserved pulmonary function in patients underwent modified radical mastectomy under general anesthesia with two different analgesic techniques; paravertebral, or intrapleural. Both analgesic techniques are equally effective in controlling postoperative pain.

In a systematic review, Richardson et al.[21] noticed less deterioration of lung function in the postoperative period of chest surgery due to improved and superior analgesia. They stated that lung functions monitoring should be available and considered as a good tool to assess the utility of different analgesic techniques' in thoracic units.

   Conclusion Top

IP as well as PVB in patients submitted for thoracoscopic sympathectomy decreased cumulative consumption of analgesics, preserved pulmonary function, and associated with less pain scores during the 1st postoperative day as compared with control group. Moreover, PVB was superior to IP with respect to duration of analgesia.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Lévy I, Ariche A, Sebbag G, Khodda J. Upper thoracic sympathectomy by thoracoscopic approach. A method of choice for the treatment of palmar hyperhidrosis. Ann Chir 1995;49:858-62.  Back to cited text no. 1
Weber A, Heger S, Sinkgraven R, Heckmann M, Elsner P, Rzany B, et al. Psychosocial aspects of patients with focal hyperhidrosis. Marked reduction of social phobia, anxiety and depression and increased quality of life after treatment with botulinum toxin A. Br J Dermatol 2005;152:342-5.  Back to cited text no. 2
Stori WS, Coelho MS, Guimarães SF, Bergonse N, Pizarro LD. Thoracic sympathetic block by clamping for treatment of hyperhidrosis. An Bras Dermatol 2006;81:425-32.  Back to cited text no. 3
Furlan AD, Mailis A, Papagapiou M. Are we paying a high price for surgical sympathectomy? A systematic literature review of late complications. J Pain 2000;1:245-57.  Back to cited text no. 4
Lima AG, Marcondes GA, Teixeira AB, Toro IF, Campos JR, Jatene FB, et al. The incidence of residual pneumothorax after video-assisted sympathectomy with and without pleural drainage and its effect on postoperative pain. J Bras Pneumol 2008;34:136-42.  Back to cited text no. 5
Silva PG, Cataneo DC, Leite F, Hasimoto EN, Barros GA. Intrapleural analgesia after endoscopic thoracic sympathectomy. Acta Cir Bras 2011;26:508-13.  Back to cited text no. 6
Assalia A, Kopelman D, Markovits R, Hashmonai M. Intrapleural analgesia following thoracoscopic sympathectomy for palmar hyperhidrosis: A prospective, randomized trial. Surg Endosc 2003;17:921-2.  Back to cited text no. 7
Orliaguet G, Carli P. Intrapleural analgesia. Ann Fr Anesth Reanim 1994;13:233-47.  Back to cited text no. 8
Richardson J, Lonnqvist PA. Thoracic paravertebral block. Br J Anaesth 1998;81:230-8.  Back to cited text no. 9
Thavaneswaran P, Rudkin GE, Cooter RD, Moyes DG, Perera CL, Maddern GJ, et al. Brief reports: Paravertebral block for anesthesia: A systematic review. Anesth Analg 2010;110:1740-4.  Back to cited text no. 10
De Cosmo G, Aceto P, Gualtieri E, Congedo E. Analgesia in thoracic surgery: Review. Minerva Anestesiol 2009;75:393-400.  Back to cited text no. 11
Lönnqvist PA, MacKenzie J, Soni AK, Conacher ID. Paravertebral blockade. Failure rate and complications. Anaesthesia 1995;50:813-5.  Back to cited text no. 12
Alastair M, Richard T. Anesthesia for endoscopic thoracic sympathectomy. Contin Educ Anesth Crit Care Pain 2009;9:51-5.  Back to cited text no. 13
Lieou FJ, Lee SC, Ho ST, Wang JJ. Interpleural bupivacaine for pain relief after transthoracic endoscopic sympathectomy for primary hyperhidrosis. Acta Anaesthesiol Sin 1996;34:21-5.  Back to cited text no. 14
El-Dawlty A, Al-Dohyayan A, Almajed M, Turkistani A, Manaa E, Elsayed M. Pain relief following thoracoscopic sympathectomy for palmer hyperhidrosis: A prospective randomized double-blind study. Middle East J Anesth 2008;19:757-77.  Back to cited text no. 15
Piraccini E, Pretto EA Jr., Corso RM, Gambale G. Analgesia for thoracic surgery: The role of paravertebral block. HSR Proc Intensive Care Cardiovasc Anesth 2011;3:157-60.  Back to cited text no. 16
Esme H, Apiliogullari B, Duran FM, Yoldas B, Bekci TT. Comparison between intermittent intravenous analgesia and intermittent paravertebral subpleural analgesia for pain relief after thoracotomy. Eur J Cardiothorac Surg 2012;41:10-3.  Back to cited text no. 17
Xu JD, Yu LN, Zhao DQ, Xie L, Zhou HY, Wang S, et al. Anesthetic effect and safety of ultrasound-guided thoracic paravertebral blockade in sympathectomy for palmar hyperhidrosis: A randomized controlled trial. Nan Fang Yi Ke Da Xue Xue Bao 2016;36:1655-9.  Back to cited text no. 18
Fujii T, Shibata Y, Ban Y, Shitaokoshi A, Nishiwaki K. Catheterization in an ultrasound-guided thoracic paravertebral block using thoracoscopy. Asian J Anesthesiol 2017;55:24-5.  Back to cited text no. 19
Kundra P, Varadharajan R, Yuvaraj K, Vinayagam S. Comparison of paravertebral and interpleural block in patients undergoing modified radical mastectomy. J Anaesthesiol Clin Pharmacol 2013;29:459-64.  Back to cited text no. 20
[PUBMED]  [Full text]  
Richardson J, Sabanathan S, Shah R. Post-thoracotomy spirometric lung function: The effect of analgesia. A review. J Cardiovasc Surg (Torino) 1999;40:445-56.  Back to cited text no. 21


  [Figure 1], [Figure 3], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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