Paravertebral Anesthetic Nerve Block for Pain Control After Peroral Endoscopic Myotomy


      Background And Aims

      Excess postoperative opioid medication use can delay recovery and is associated with long-term misuse, addiction, and overdose. We aimed to explore the effect of preprocedural thoracic paravertebral nerve block (PNB) on pain-related outcomes after POEM.


      In this retrospective cohort study, consecutive patients who did and did not receive a PNB prior to POEM were compared. The outcomes were peak and cumulative pain scores, total opioid use during hospitalization, and length of stay. After adjusting for confounders, the associations between nerve block and the outcomes of interest were explored.


      Forty-nine consecutive patients were enrolled; 25 patients received a block whereas the subsequent 24 did not. There were no differences in baseline characteristics between the study groups. In unadjusted analyses, there was no significant difference between patients who did and did not undergo PNB in peak pain score (7.8 vs 8.7, P = 0.14), cumulative pain score in the first 12 hours (area under curve 66.5 vs 75.8, P = 0.22), median total opioid use (38.9 mg morphine equivalent dosing vs 42, P = 1.00), and median length of hospitalization (26.5 hours vs 24, P = 0.35). In multivariable regression models, PNB was not associated with a reduction in pain scores, opioid use, or hospitalization. There were no adverse events related to the block.


      In this exploratory, observational study, paravertebral nerve block immediately before POEM did not result in a statistically significant reduction in pain-related outcomes or hospitalization. Additional observational studies may elucidate whether higher anesthetic doses or longer acting formulations would be of value.


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        • Ponds FA
        • Fockens P
        • Lei A
        • Neuhaus H
        • Beyna T
        • Kandler J
        • et al.
        Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial.
        JAMA. 2019; 322: 134-144
        • Werner YB
        • Hakanson B
        • Martinek J
        • Repici A
        • von Rahden BHA
        • Bredenoord AJ
        • et al.
        Endoscopic or surgical myotomy in patients with idiopathic achalasia.
        N Engl J Med. 2019; 381: 2219-2229
        • Kahrilas PJ
        • Katzka D
        • Richter JE.
        Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute.
        Gastroenterology. 2017 Nov; 153: 1205-1211
        • Misra L
        • Fukami N
        • Nikolic K
        • Trentman TL.
        Peroral endoscopic myotomy: procedural complications and pain management for the perioperative clinician.
        Med Devices. 2017; 10: 53-59
        • Werner YB
        • von Renteln D
        • Noder T
        • Schachschal G
        • Denzer UW
        • Groth S
        • et al.
        Early adverse events of peroral endoscopic myotomy.
        Gastrointest Endosc. 2016; 85: 708-718
        • Brat GA
        • Agniel D
        • Beam A
        • Yorkgitis B
        • Bicket M
        • Homer M
        • et al.
        Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study.
        BMJ. 2018; 360: j5790
        • Brummett CM
        • Waljee JF
        • Goesling J
        • Moser S
        • Lin P
        • Englesbe MJ
        • et al.
        New persistent opioid use after minor and major surgical procedures in US adults.
        JAMA Surg. 2021; 152 (e170504-e170): 504
        • Johnson SP
        • Chung KC
        • Zhong L
        • Shauver MJ
        • Engelsbe MJ
        • Brummett C
        • et al.
        Risk of prolonged opioid use among opioid-naïve patients following common hand surgery procedures.
        J Hand Surg Am. 2016; 41 (e3): 947-957
        • Richter JE
        • Bradley LC.
        Psychophysiological interactions in esophageal diseases.
        Semin Gastrointest Dis. 1996; 7: 169-184
        • Song CW
        • Lee SJ
        • Jeen YT
        • et al.
        Inconsistent association of esophageal symptoms, psychometric abnormalities and dysmotility.
        Am J Gastroenterol. 2001; 96 (231): 2-6
        • Aziz Q
        • Fass R
        • Gyawali CP
        • Miwa H
        • Pandolfino JE
        • Zerbib F
        Functional Esophageal Disorders.
        Gastroenterology. 2016 Feb 15; (pii: S0016-508500178): 5
        • Hu Z
        • Liu D
        • Wang ZZ
        • Wang B
        • Dai T.
        The efficacy of thoracic paravertebral block for thoracoscopic surgery: A meta-analysis of randomized controlled trials.
        Medicine (Baltimore). 2018; 97: e13771
        • Concha M
        • Dagnino J
        • Cariaga M
        • Aguilera J
        • Aparicio R
        • Guerrero M
        Analgesia after thoracotomy: epidural fentanyl/bupivacaine compared with intercostal nerve block plus intravenous morphine.
        J Cardiothorac Vasc Anesth. 2004; 18: 322-326
        • Docimo Jr, S
        • Mathew A
        • Shope AJ
        • Winder JS
        • Haluck RS
        • Pauli EM
        Reduced postoperative pain scores and narcotic use favor per-oral endoscopic myotomy over laparoscopic Heller myotomy.
        Surg Endosc. 2017; 31: 795-800
        • Chan SM
        • Wu JC
        • Teoh AY
        • Yip HC
        • Ng EK
        • Lau JY
        • et al.
        Comparison of early outcomes and quality of life after laparoscopic Heller's cardiomyotomy to peroral endoscopic myotomy for treatment of achalasia.
        Dig Endosc. 2016; 28: 27-32
        • Ladha KS
        • Neuman MD
        • Broms G
        • Bethell J
        • Bateman BT
        • Wijeysundera DN
        • et al.
        Opioid Prescribing After Surgery in the United States, Canada, and Sweden.
        JAMA Netw Open. 2019; 2 (PMID: 31483475; PMCID: PMC6727684): e1910734