Commentary: Waves of pain.

Trends influencing thoracic surgery pain management.

Trend analyses of administrative databases may be a better way of interpreting data, especially when surgical and anesthesia systems are undergoing marked changes caused by disruptive new technology.

See Article page 224.

The article by Lo and colleagues in this issue of JTCVS Open provides important information gained by studying clinical outcomes over time and stands as a very important companion article to that recently published by Rajaram and colleagues, who used a subset from the same database. The latter study (funded by ) observed less opioid usage for robotic compared with thoracoscopic or open lobectomy. In a commentary on that article, I proposed the need to tabulate many more factors contributing to postoperative thoracic surgical pain before attributing its cause.

Such factors as incision size, number, and location could be used to test mechanistic theories to explain why postoperative pain may differ among approaches. Besides individual factors, health care trends cause very rapid practice changes, as documented by Lo and colleagues. The reader should study their trend lines from 2013 to 2015, which were the subset years selected by researchers in the Rajaram study, in which a salutary effect of robotic-assisted thoracic surgery (RATS) was observed. During this interval, pain control therapy was still undergoing major transitions, such as a reduction in the use of epidural anesthesia.

Around the same time as the opioid crisis wave of change, other authors trended the shift to minimally invasive lobectomy preference in the Society of Thoracic Surgeons database. It would have been interesting to plot the proportion of open to less invasive approaches to the changes in anesthetic management. Contemporaneously, a group of surgeons adopted RATS who had the selective advantage of previous video-assisted thoracic surgery (VATS) skills or the institutional resources needed to support robotics. Because of fewer centers and the holistic nature of robotic training, it is reasonable to believe that these surgeons adopted a more uniform cluster of good techniques and perioperative pain control practices. Those practices unrelated to core RATS technology would still be observed as an approach effect when measuring the anesthesia trends and opioid usage reported by Lo and colleagues and Rajaram and colleagues. Arguably, repeating the Rajaram analysis during a time when practice change waves for both anesthetic methods and surgical approaches are reasonably stable could assuage concerns about bias from unmeasured covariates.

Along with events like the opioid crisis, change waves have been initiated by new technology releases, such as articulating endoscopic staplers that enabled use of anterior (less painful) VATS port locations. High-resolution scopes (and 3-dimensional optics) similarly improved outcomes.,

Adopting guidelines creates waves by rapidly eliminating ineffective perioperative management methods. The currently popular ERAS (Enhanced Recovery After Surgery) guidelines incorporate many pain management elements. Guidelines provide a shorthand means of documenting and trending potentially diverse current institutional practices. If incorporated, prospective registries and administrative databases could document whether or not a particular patient's care was compliant with perioperative pain control regimens too impractical to atomize. Surgical incision sets both for VATS and RATS are also diverse but generally fall into common clusters documentable in a shorthand fashion.

Surgeons improve by changing individual practices which if divergent make our specialty outcomes broadly less uniform. We should embrace trend analyses, unifying guidelines, and systematic technical documentation to better understand the impact of our technical preferences.