Pre-emptive local anesthesia for needlescopic video-assisted thoracic surgery: a randomized controlled trial

Loco-Regional Anesthesia for Pain Management in Robotic Thoracic Surgery

Robotic thoracic surgery is a prominent minimally invasive approach for the treatment of various thoracic diseases. While this technique offers numerous benefits including reduced blood loss, shorter hospital stays, and less postoperative pain, effective pain management remains crucial to enhance recovery and minimize complications. This review focuses on the application of various loco-regional anesthesia techniques in robotic thoracic surgery, particularly emphasizing their role in pain management. Techniques such as local infiltration anesthesia (LIA), thoracic epidural anesthesia (TEA), paravertebral block (PVB), intercostal nerve block (INB), and erector spinae plane block (ESPB) are explored in detail regarding their methodologies, benefits, and potential limitations. The review also discusses the imperative of integrating these anesthesia methods with robotic surgery to optimize patient outcomes. The findings suggest that while each technique has unique advantages, the choice of anesthesia should be tailored to the patient's clinical status, the complexity of the surgery, and the specific requirements of robotic thoracic procedures. The review concludes that a multimodal analgesia strategy, potentially incorporating several of these techniques, may offer the most effective approach for managing perioperative pain in robotic thoracic surgery. Future directions include refining these techniques through technological advancements like ultrasound guidance and exploring the long-term impacts of loco-regional anesthesia on patient recovery and surgical outcomes in the context of robotic thoracic surgery.

Enhanced Recovery After Surgery Program and Opioid Consumption in Pulmonary Resection Surgery: A Retrospective Observational Study

BACKGROUND

Pulmonary resection surgery causes severe postoperative pain and usually requires opioid-based analgesia, particularly in the early postoperative period. However, the administration of large amounts of opioids is associated with various adverse events. We hypothesized that patients who underwent pulmonary resection under an enhanced recovery after surgery (ERAS) program consumed fewer opioids than patients who received conventional treatment.

METHODS

A total of 2147 patients underwent pulmonary resection surgery between August 2019 and December 2020. Two surgeons (25%) at our institution implemented the ERAS program for their patients. After screening, the patients were divided into the ERAS and conventional groups based on the treatment they received. The 2 groups were then compared after the stabilized inverse probability of treatment weighting. The primary end point was the total amount of opioid consumption from surgery to discharge. The secondary end points included daily average and highest pain intensity scores during exertion, opioid-related adverse events, and clinical outcomes, such as length of intensive care unit (ICU) stay, hospital stay, and postoperative complication grade defined by the Clavien-Dindo classification. Additionally, the number of patients discharged without opioids prescription was assessed.

RESULTS

Finally, 2120 patients were included in the analysis. The total amount of opioid consumption (median [interquartile range]) after surgery until discharge was lower in the ERAS group (n = 260) than that in the conventional group (n = 1860; morphine milligram equivalents, 44 [16-122] mg vs 208 [146-294] mg; median difference, -143 mg; 95% CI, -154 to -132; P < .001). The number of patients discharged without opioids prescription was higher in the ERAS group (156/260 [60%] vs 329/1860 [18%]; odds ratio, 7.0; 95% CI, 5.3-9.3; P < .001). On operation day, both average pain intensity score during exertion (3.0 ± 1.7 vs 3.5 ± 1.8; mean difference, -0.5; 95% CI, -0.8 to -0.3; P < .001) and the highest pain intensity score during exertion (5.5 ± 2.1 vs 6.4 ± 1.7; mean difference, -0.8; 95% CI, -1.0 to -0.5; P < .001) were lower in the ERAS group than in the conventional group. There were no significant differences in the length of ICU stay, hospital stay, or Clavien-Dindo classification grade.

CONCLUSIONS

Patients who underwent pulmonary resection under the ERAS program consumed fewer opioids than those who received conventional management while maintaining no significant differences in clinical outcomes.

Effect of balanced opioid-free anaesthesia on postoperative nausea and vomiting after video-assisted thoracoscopic lung resection: protocol for a randomised controlled trial

INTRODUCTION

Opioid-free anaesthesia (OFA) may reduce opioid-related side effects such as postoperative nausea and vomiting (PONV) and hyperalgesia. This study aims to investigate the effects of balanced OFA on PONV and pain outcomes in patients undergoing video-assisted thoracoscopic surgery (VATS).

METHODS AND ANALYSIS

This randomised controlled trial will be conducted at the First Affiliated Hospital of Soochow University in Suzhou, China. A total of 120 adults scheduled for VATS lung resection will be randomly assigned with a 1:1 ratio to either an OFA group or a control group, stratified by sex (n=60 in each group). Patients will receive balanced anaesthesia with esketamine, dexmedetomidine and sevoflurane (the OFA group), or sufentanil and sevoflurane (the control group). All patients will receive PONV prophylaxis with intraoperative dexamethasone and ondansetron. Multimodal analgesia consists of intraoperative flurbiprofen axetil, ropivacaine infiltration at the end of surgery and postoperative patient-controlled sufentanil. The primary outcome is the incidence of PONV within 48 hours after surgery. Secondary outcomes are nausea, vomiting, need for antiemetic therapy, pain scores at rest and while coughing, postoperative sufentanil consumption, need for rescue analgesia, length of post-anaesthesia care unit stay, length of postoperative hospital stay, and 30-day and 90-day post-surgical pain and mortality. Safety outcomes are hypotension, bradycardia, hypertension, tachycardia, interventions for haemodynamic events, level of sedation, headache, dizziness, nightmare and hallucination. All analyses will be performed in the modified intention-to-treat population.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the First Affiliated Hospital of Soochow University (2022-042). All patients will provide written informed consent. The results of this study will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2200059710).

Evaluation of pain and opioid consumption in local preemptive anesthesia and the erector spine plane block in thoracoscopic surgery: A randomized clinical trial

OBJECTIVE

assess pain and opioid consumption in patients undergoing anesthetic techniques of spinal erector plane block and local anesthetic block in video-assisted thoracic surgery in the immediate postoperative period.

METHODS

ninety-two patients undergoing video assisted thoracic surgery were randomized to receive ESPB or BAL before starting the surgical procedure. Using the numerical verbal scale, the primary outcome assessed was the patient's pain in the immediate postoperative period (POI). The secondary outcome comprises the assessment of opioid consumption in the IPP by quantifying the medication used in an equianalgesic dose of morphine expressed in milligrams, in the immediate post-anesthetic recovery period, 6h, 12h, and 24h after surgery.

RESULTS

the EVN scores in the LBA and ESPB group in the POI had a mean of 0,8 (±1,89) vs 0,58 (±2,02) in the post-anesthesia care room (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) in 6 hours of POI, 0,84 (±1,74) vs 1,19 (±2,01) within 12 hours of POI and 0,95 (±1,88) vs 1 ( ±1,66) within 24 hours of POI, all with p>0.05. Mean opioid consumption in the BAL and ESPB groups in the POI was 12.9 (± 10.4) mg vs 14.9 (±10.2) mg, respectively, with p = 0.416. Sixteen participants in the ESPB group and seventeen in the BAL group did not use opioids during the first 24 hours of the PO analyzed.

CONCLUSION

local anesthesic block and ESP block techniques showed similar results in terms of low pain scores and opioid consumption during the period evaluated.

Avaliação da dor e consumo de opioides em anestesia preemptiva local e do plano eretor da espinha em cirurgia torácica videotoracoscópica: Um ensaio clínico randomizado

RESUMO Objetivo: avaliar a dor e o consumo de opioides dos pacientes submetidos a técnicas anestésicas de bloqueio do plano eretor da espinha (ESPB) e bloqueio anestésico local (LBA) em cirurgia torácica vídeo assistida no período pós-operatório imediato (POI). Métodos: noventa e dois pacientes submetidos a cirurgia torácica videotoracoscópica foram randomizados aleatoriamente para receberem ESPB ou LBA antes do início do procedimento cirúrgico. O desfecho primário avaliado foi a dor do paciente no POI através da escala verbal numérica. O desfecho secundário avaliou o consumo de opioides através da quantificação da medicação usada em dose equianalgésica de morfina expressa em miligramas, no período de recuperação pós-anestésica imediata, 6h, 12h e 24h após a cirurgia. Resultados: os escores da Escala Verbal Numérica de dor (EVN) no grupo LBA e ESPB no POI, respectivamente, tiveram média de 0,8 (±1,89) vs 0,58 (±2,02) na sala de recuperação pós anestesia (REPAI), 1,06 (±2,00) vs 1,30 (±2,30) em 6 horas do POI, 0,84 (±1,74) vs 1,19 (±2,01) em 12 horas do POI e 0,95 (±1,88) vs 1 ( ±1,66) em 24 horas do POI, todos com p>0,05. O consumo médio de opioides no grupo LBA e ESPB foi de 12,9 (±10,4) mg vs 14,9 (±10.2) mg, respectivamente, com p=0.416. Dezesseis participantes do grupo ESPB e dezessete do grupo LBA não utilizaram opioides durante as primeiras 24 horas do PO. Conclusões: as técnicas de bloqueio LBA e ESPB apresentaram resultados semelhantes em termos de baixos escores de dor e consumo de opioides durante o período avaliado.

Updates on Wound Infiltration Use for Postoperative Pain Management: A Narrative Review

Local anesthetic wound infiltration (WI) provides anesthesia for minor surgical procedures and improves postoperative analgesia as part of multimodal analgesia after general or regional anesthesia. Although pre-incisional block is preferable, in practice WI is usually done at the end of surgery. WI performed as a continuous modality reduces analgesics, prolongs the duration of analgesia, and enhances the patient’s mobilization in some cases. WI benefits are documented in open abdominal surgeries (Caesarean section, colorectal surgery, abdominal hysterectomy, herniorrhaphy), laparoscopic cholecystectomy, oncological breast surgeries, laminectomy, hallux valgus surgery, and radical prostatectomy. Surgical site infiltration requires knowledge of anatomy and the pain origin for a procedure, systematic extensive infiltration of local anesthetic in various tissue planes under direct visualization before wound closure or subcutaneously along the incision. Because the incidence of local anesthetic systemic toxicity is 11% after subcutaneous WI, appropriate local anesthetic dosing is crucial. The risk of wound infection is related to the infection incidence after each particular surgery. For WI to fully meet patient and physician expectations, mastery of the technique, patient education, appropriate local anesthetic dosing and management of the surgical wound with “aseptic, non-touch” technique are needed.

AAAPT Diagnostic Criteria for Acute Thoracic Surgery Pain

Patients undergoing thoracic surgery experience particular challenges for acute pain management. Availability of standardized diagnostic criteria for identification of acute pain after thoracotomy and video assisted thoracic surgery (VATS) would provide a foundation for evidence-based management and facilitate future research. The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the United States Food and Drug Administration, the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) formed the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) initiative to address absence of acute pain diagnostic criteria. A multidisciplinary working group of pain experts was invited to develop diagnostic criteria for acute thoracotomy and VATS pain. The working group used available studies and expert opinion to characterize acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (i.e., core diagnostic criteria, common features, modulating factors, impact/functional consequences, and putative mechanisms). The resulting diagnostic criteria will serve as the starting point for subsequent empirically validated criteria. PERSPECTIVE ITEM: This article characterizes acute pain after thoracotomy and VATS using the 5-dimension taxonomical structure proposed by AAAPT (ie, core diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms).

The Anesthetic Management of Patients Undergoing Nonintubated Video-Assisted Thoracic Surgery

Purpose of Review

This review focuses on describing the procedural and anesthetic management of patients undergoing nonintubated video-assisted thoracoscopy surgery.

Recent Findings

Most thoracic surgery is performed under general endotracheal anesthesia with either a double lumen endotracheal tube or a bronchial blocker. In an attempt to lessen the incidence and severity of postoperative complications, the nonintubated video-assisted thoracoscopic technique was developed, where the surgical procedure is performed under regional anesthesia with sedation. Currently, this technique is recommended for the elderly and in patients with severe cardiopulmonary disease who are at increased risk of complications after general anesthesia. It is the role of the anesthesia team to assist in the decisions whether the patient is a candidate and which block should be performed and to carefully monitor these patients in the operating room.

Summary

Nonintubated video-assisted thoracic surgery is an emerging technique with the goal of reducing postoperative complications. The anesthetic technique is highly variable and ranges from general anesthesia with a laryngeal mask airway with a truncal block to thoracic epidural anesthesia with minimal to no block. It is important to have excellent communication with the surgical team and the patient to ensure a safe, successful procedure.

Analgesic Effect of Serratus Anterior Plane Block After Thoracoscopic Surgery: A Randomized Controlled Double-Blinded Study

Purpose

Fast-track surgery is a developing trend in medical care. It is a core challenge for clinical anesthesia to reasonably reduce the dosage of opioids and relieve postoperative pain. Serratus anterior plane block (SAPB) is a novel analgesic technique with such advantages as easy operation, good safety, and few side effects.

Patients and Methods

In total, 60 patients aged 18 to 65 years who were diagnosed with lung cancer and scheduled for thoracoscopic resection were randomly assigned to receive SABP or local infiltration anesthesia. We analyzed the time within 48 hrs after operation to visual analogue scale (VAS) pain score of 4 or higher and the number of patients requiring additional analgesics at 6 hrs and 12 hrs after operation.

Results

The estimated median time to VAS ≥4 was 4 hrs (1.32 to 6.68) in the control group and 11 hrs (6.71 to 15.29) in the SAPB group (log-rank test: P=0.008). The number of patients requiring additional analgesics at 6- and 12 hrs after operation was significantly lower in the SAPB group than that in the control group (P<0.05).

Conclusion

Compared with local infiltration, SAPB provided extended postoperative analgesia after thoracoscopic surgery with reduced consumption of additional analgesics in the early postoperative stage.

Video-assisted thoracoscopic surgery as the gold standard for lung cancer surgery

Surgical resection remains the only effective means of cure in the vast majority of patients with early-stage lung cancer. It can be performed via a traditional open approach (particularly thoracotomy) or a minimally invasive approach. VATS is 'keyhole' surgery in the chest, and was first used for lung cancer resection in the early 1990s. Since then, a large volume of evolving clinical evidence has confirmed that VATS lung cancer resection offered proven safety and feasibility, better patient-reported post-operative outcomes, less surgical trauma as quantified by objective outcome measures and equivalent or better survival than open surgery. This has firmly established VATS as the surgical approach of choice for early-stage lung cancer today. Although impressive new non-surgical lung cancer therapies have emerged in recent years, VATS is also being constantly rejuvenated by the development of 'next generation' VATS techniques, the refinement of VATS sublobar resection for selected patients, the utilization of bespoke post-operative recovery programmes for VATS and the synthesis of VATS into multi-modality lung cancer therapy. There is little doubt that VATS will remain as the gold standard for lung cancer surgery for the foreseeable future.

Devising the guidelines: the concept of uniportal video-assisted thoracoscopic surgery-incisions and anesthetic management

Uniportal video-assisted thoracoscopic surgery (VATS) is an already established minimally invasive technique in the field of thoracic surgery. The feasibility, safety and efficacy of the technique are already well documented. Comparative studies and meta-analyses have shown a clear advantage over open surgery and other minimally invasive techniques in terms of pain, length of stay (LOS), chest drain duration and morbidity. It covers a broad spectrum of indications for both malignant and benign diseases, including pulmonary and mediastinal tumor resections, diaphragm procedures (plication), esophageal surgery and airway surgery (bronchial resections, carinal resections). Its swift and wide adoption has resulted into many variations, all of whom are common in the fact they utilize a single incision to enter the chest and conduct the planned procedure. With this article, we attempt to standardize the technique as to the incision and the anesthetic management.

Effects of serratus anterior plane block for postoperative analgesia after thoracoscopic surgery compared with local anesthetic infiltration: a randomized clinical trial

Background

Serratus anterior plane (SAP) block is a relatively novel technique that can block the lateral cutaneous branches of the intercostal nerves as well as the long thoracic nerve.

Purpose

Our study aimed to evaluate the effects of SAP block on postoperative pain after thoracoscopic surgery compared with local anesthetic (LA) infiltration.

Patients and methods

Forty adult patients undergoing video-assisted thoracic surgery were randomized to receive either SAP block (n=20) or LA infiltration of incision (n=20). The primary outcome was postoperative visual analog scale (VAS) score at the 2nd, 8th, 16th, 24th, and 48th hour after surgery. The secondary outcomes were the consumption of sufentanil at 8th, 16th, 24th hours postoperative. In addition, rescue analgesia, drug-related adverse effects after surgery was also analyzed.

Results

The SAP group showed lower VAS scores at the 2nd hour (at rest: SAP group 11 [8-13] vs LA group 28 [26-32], P=0.01; on coughing: 15 [13-18] vs 33 [26-38], P=0.01) and the 8th hour (at rest: 13 [12-18] vs 36 [32-46], P=0.01; on coughing: 19 [16-23] vs 42 [36-53], P=0.01) after surgery. Postoperative sufentanil consumption in the SAP group during 0-8 hrs was significantly lower compared with the LA group (P<0.01). The use of rescue analgesia was also significantly lower in the SAP group (P=0.02) during 0-12 hrs.

Conclusion

Compared to LA infiltration, ultrasound-guided SAP block may provide better pain relief as well as reduce opioid consumption after thoracoscopic surgery.

Preventive skin analgesia with lidocaine patch for management of post-thoracotomy pain: Results of a randomized, double blind, placebo controlled study

Background

To evaluate whether pre‐emptive skin analgesia using a lidocaine patch 5% would improve the effects of systemic morphine analgesia for controlling acute post‐thoracotomy pain.

Methods

This was a double‐blind, placebo controlled, prospective study. Patients were randomly assigned to receive lidocaine 5% patch (lidocaine group) or a placebo (placebo group) three days before thoracotomy. Postoperative analgesia was induced in all cases with intravenous morphine analgesia. The intergroup differences were assessed in order to evaluate whether the lidocaine patch 5% would have effects on pain intensity when at rest and after coughing (primary end‐point) on morphine consumption, on the recovery of respiratory function, and on peripheral painful pathways measured with N2 and P2 laser‐evoked potential (secondary end‐points).

Results

A total of 90 patients were randomized, of whom 45 were allocated to the lidocaine group and 45 to the placebo group. Lidocaine compared with the placebo group showed a significant reduction in pain intensity both at rest (P = 0.013) and after coughing (P = 0.015), and in total morphine consumption (P = 0.001); and also showed a better recovery of flow expiratory volume in one second (P = 0.025) and of forced vital capacity (P = 0.037). The placebo group compared with the lidocaine group presented a reduction in amplitude of N2 (P = 0.001) and P2 (P = 0.03), and an increase in the latency of N2 (P = 0.023) and P2 (P = 0.025) laser‐evoked potential.

Conclusions

The preventive skin analgesia with lidocaine patch 5% seems to be a valid adjunct to intravenous morphine analgesia for controlling post‐thoracotomy pain. However, our initial results should be corroborated/confirmed by larger studies.

Anaesthesiology for uniportal VATS: double lumen, single lumen and tubeless

The advent of one-lung ventilation (OLV) technique provides immobilized surgical field which is fundamental in minimally invasive thoracic surgery. Mainstem methods of achieving lung separation are either via a double-lumen endotracheal tube or placing a bronchial blocker (BB) through a single-lumen endotracheal tube. More recently, the use of non-intubated thoracic surgery (NITS) has been investigated intensively, attempting to minimise the complications that follow general anaesthesia. The aim of this review is to describe the mechanism of these techniques briefly and outlines the advantages and drawbacks of them with the comparison.

Adherence to a Clinical Pathway for Video-Assisted Thoracic Surgery: Predictors and Clinical Importance

OBJECTIVE

A bespoke clinical pathway is increasingly often used to expedite patient's recovery after video-assisted thoracoscopic surgery (VATS). The importance and predictors of adherence to a clinical pathway have not been previously investigated.

METHODS

A defined clinical pathway was used for the perioperative management of 136 consecutive patients receiving major pulmonary resection surgery. The clinical pathway encompassed multiple aspects of clinical care, including chest drainage, analgesia, mobilization, physiotherapy, investigations, etc.

RESULTS

The cohort consisted of 76 males (56%), and had a median age of 61 years (range, 14-84). A single lobectomy was performed in 66 patients (49%), with sublobar or more complex resections performed in the remainder. Although all patients were intended for a VATS approach, VATS was ultimately used to complete the procedure in 113 patients (83%). It was impossible to adhere strictly to the clinical pathway throughout the hospital stay of most patients, with 83 patients (61%) found to have adhered to the clinical pathway for 50% or more or the duration of their in-hospital stay. The rate of adherence to the clinical pathway for 50% or more of the time was lower in patients who were male (31.6% vs 48.3%, P = 0.047); had a smoking history (25.9% vs 47.6%, P = 0.011); and did not have absence of pain immediately after surgery (33.9% vs 59.3%, P = 0.016). There were trends for poorer adherence among patients who had: age older than 65 years; previous tuberculosis; body mass index greater than 25 kg/m; and longer operation times-but these failed to reach statistical significance. The approach and extent of surgery did not influence clinical pathway adherence. Adherence for 50% or more of the hospital stay was associated with reduced mean chest drain duration (3.2 ± 1.7 vs 5.1 ± 5.0 days, P = 0.002) and mean length of stay (4.6 ± 1.9 vs 7.9 ± 6.6 days, P < 0.001). Among smokers, adherence for 75% or more of the hospital stay was particularly well predicted by better pain control on the day of surgery, and was in turn associated with a significant reduction in morbidity rate (7.7% vs 39.0%, P = 0.043).

CONCLUSIONS

Good adherence to a detailed clinical pathway may ensure faster recovery after VATS but is often difficult to maintain postoperatively. Predictors of poor adherence include male sex, smoking history, and immediate postoperative pain. Smokers are at particular risk for failure to adhere but paradoxically have the most to gain from adhering to the clinical pathway.

Role of Surgery in the Diagnosis and Management of Tuberculosis

Modern thoracic surgery can now offer management of tuberculosis and its complications in selected patients with greater efficacy and less morbidity than ever before. Significantly, newer minimally invasive thoracic surgical approaches potentially lower thresholds for surgical candidacy, allowing more tuberculosis patients to receive operative treatment. This review aims to provide an overview of the role that modern thoracic surgery can play in diagnosing and managing patients with tuberculosis and its sequelae.

Reasons not to perform uniportal VATS lobectomy

The uniportal video assisted thoracic surgery (VATS) approach to lung lobectomy has generated phenomenal interest in recent years. It promises to offer patients less morbidity and faster recovery, even when compared to conventional multiportal VATS. However, critics of the uniportal VATS approach may raise concerns about whether this most minimally invasive surgical approach for lung surgery may compromise safety and treatment efficacy. This debate has great potential importance not only in determining how patients are operated on, but in understanding how 'success' is gauged in major pulmonary surgery. This article explores both sides of this debate, drawing on the experience of how clinical research in multiportal VATS evolved over the years. Systematic generation of clinical evidence with progressively increasing sophistication is required to fairly evaluate the uniportal VATS approach. A review of the current literature suggests that there remain many large gaps in the evidence surrounding uniportal VATS. Hence, at the present time, the reasons voiced by critics as to why uniportal VATS should not be performed should not be lightly dismissed. Instead, it behoves surgeons on both sides of the debate to continue to generate good clinical evidence to resolve it.

Clinical pathway for video-assisted thoracic surgery: the Hong Kong story

A clinical pathway provides a scheduled, objective protocol for the multi-disciplinary, evidence-based management of patients with a specific condition or undergoing a specific procedure. In implementing a clinical pathway for the care of patients receiving video-assisted thoracic surgery (VATS) in Hong Kong, many insights were gained into what makes a clinical pathway work: meticulous preparation and team-building are keys to success; the pathway must be constantly reviewed and revisions made in response to evolving clinical need; and data collection is a key element to allow auditing and clinical research. If these can be achieved, a clinical pathway delivers not only measurable improvements in patient outcomes, but also fundamentally complements clinical advances such as VATS. This article narrates the story of how the clinical pathway for VATS in Hong Kong was created and evolved, highlighting how the above lessons were learned.

Uniportal versus three-port video-assisted thoracoscopic surgery for spontaneous pneumothorax: a meta-analysis

BACKGROUND

Whether or not uniportal video-assisted thoracoscopic surgery (VATS) is beneficial for spontaneous pneumothorax remains inconclusive. This meta-analysis aimed to summarize the available evidence to assess the feasibility and advantages of uniportal VATS for the treatment of spontaneous pneumothorax compared with three-port VATS.

METHODS

Eligible publications were identified by searching the Cochrane Library, PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), Wanfang Data databases and CQVIP. Odds ratios (OR) and standardized mean differences (SMD) with 95% confidence intervals (CI) were calculated to compare dichotomous and continuous variables, respectively.

RESULTS

This meta-analysis was based on 17 studies and included a total of 988 patients with spontaneous pneumothorax. No death was reported during the perioperative period. Compared with three-port VATS groups, there was a statistically significant difference in uniportal VATS groups regarding postoperative hospital stay (SMD= -0.58; 95% CI: -1.04 to -0.12; P=0.01), paresthesia (OR=0.13; 95% CI: 0.07 to 0.24; P<0.00001), visual analogue pain score (VAS) at 24 hours (h) (SMD= -0.87; 95% CI: -1.07 to -0.68; P<0.00001), VAS at 72 h (SMD= -0.49; 95% CI: -0.68 to -0.30; P<0.00001), and patients satisfaction scale (PSS) at 24 h (SMD= -0.81; 95% CI: -1.21 to -0.41; P<0.0001), PSS at 48 h (SMD= -0.69; 95% CI: -1.08 to -0.29; P=0.0007). However there was no statistically significant difference on the recurrence (OR=0.79; 95% CI: 0.42 to 1.46; P=0.45), operative time (SMD= -0.23; 95% CI: -0.21 to 0.67; P=0.31), length of postoperative drainage (SMD= -0.17; 95% CI: -0.40 to -0.07; P=0.16), VAS at 48 h (SMD= -0.40; 95% CI: -1.47 to 0.67; P=0.46), and PSS at 72 h (SMD= -0.13; 95% CI: -0.52 to -0.25; P=0.50).

CONCLUSIONS

The results for mortality, recurrence, operative time, and length of postoperative drainage were similar between uniportal and three-port VATS. Uniportal VATS resulted in reduction in postoperative pain and paresthesia as well as an improvement in patients' satisfaction. This meta-analysis indicated that using uniportal VATS to treat spontaneous pneumothorax was safe and feasible, and it may be a better alternative procedure because of its advantage in reducing postoperative pain and paresthesia.

Pain control of thoracoscopic major pulmonary resection: is pre-emptive local bupivacaine injection able to replace the intravenous patient controlled analgesia?

BACKGROUND

The aim of this open-label, non-inferiority trial was to evaluate whether pre-emptive local bupivacaine injection (PLBI) can replace intravenous patient controlled analgesia (IV PCA) in video-assisted thoracic surgery (VATS) major pulmonary resection.

METHODS

A total of 86 patients scheduled for VATS segmentectomy/lobectomy were randomly assigned into two groups. The PLBI group (n=42) received 0.5% bupivacaine wound infiltration before skin incision, and the IV PCA group (n=44) received a continuous infusion of fentanyl with a basal rate of 10 µg/mL/h. Visual analogue scale (VAS; range, 0-10) was measured as the primary endpoint. The secondary endpoint was an additional use of analgesics and drug induced side effects.

RESULTS

Both groups showed no difference in terms of age, sex, disease entity, operation time, chest tube indwelling time, and hospital stay. Serial pain scores between the PLBI and IV PCA groups demonstrated no statistical differences (non-inferiority margin; ΔVAS =1.0) (Recovery room: 8.3±2.1 vs. 8.5±1.7; Day 0: 5.1±1.6 vs. 5.2±1.4; Day 1: 3.5±1.6 vs. 3.3±1.2; Day 2: 2.7±1.3 vs. 2.5±1.2; Day 3: 2.3±1.3 vs. 2.1±1.5; 1 week after discharge: 3.0±1.7 vs. 2.8±1.5; 1 month: 1.9±1.2 vs. 2.3±1.4 and 2 months: 1.5±1.2 vs. 1.3±1.2; 95% confidential interval (CI) of ΔVAS <1.0; P>0.05). The mean one-additional usage of IV analgesics was needed in the PLBI group (3.3±2.1 vs. 2.3±1.3; P=0.03). The occurrence of nausea/vomiting was higher in the IV PCA group (12.5% vs. 38.9%; P=0.026) and 41.7% of IV PCA patients experienced drug side effects that required IV PCA removal within postoperative day (POD) 1.

CONCLUSIONS

PLBI is a simple, safe, effective, and economical method, which is not inferior to IV PCA in VATS major pulmonary resection.

Electric vs. harmonic scalpel in treatment of primary focal hyperhidrosis with thoracoscopic sympathectomy

BACKGROUND

Hyperhidrosis is defined as excessive sweating beyond the physiologic needs of a person. Palmar hyperhidrosis in the adolescent period may have an impact on school work and may cause psychological problems. Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing.

PATIENTS AND METHODS

From January 2008 to December of 2009 bilateral thoracoscopic sympathectomy Th2-Th4 was performed to 79 patients aged from 17 to 55, who suffered from palmar, axillar or craniofacial hyperhidrosis. For the first 39 patients (group A) thoracoscopic sympathectomy was performed using electric scalpel and for the next 40 patients (group B) thoracoscopic sympathectomy was performed using harmonic scalpel.

RESULTS

Based on our results we did not find any significant differences between electric or harmonic scalpel usages for thoracoscopic sympathectomy. Moreover, there was no significant difference between complications and the severity of pain, with slightly higher intensity of pain with harmonic scalpel usage. Both electric and harmonic scalpel provided adequate treatment for primary hyperhidrosis, with the fact that non-disposable electric scalpel costs were less than that of the disposable harmonic scalpel.

CONCLUSIONS

Sympathectomy should be preferred for palmar hyperhidrosis treatment, as it is much technically shorter, simpler to implement, and also easier to learn. Thoracoscopic sympathectomy is safe and effective for the treatment of primary palmar hyperhidrosis in the adolescent period without any major side effects.

Initial management of primary spontaneous pneumothorax with video-assisted thoracoscopic surgery: a 10-year experience

OBJECTIVES

First-line conservative treatment of primary spontaneous pneumothorax (PSP) may be challenged by recurrence rates and complications associated with different treatment options. The aim of this study was to evaluate the use of a standardized surgical treatment as 'first-line' treatment.

METHODS

In a 10-year period, 185 patients with PSP were treated with a standardized video-assisted thoracic surgery (VATS) approach including wedge resection and parietal pleurectomy. Data were evaluated retrospectively. All patients with a first event of PSP were included in the study. In addition, follow-up was done by a questionnaire.

RESULTS

Mean follow-up period was 70.8 months (±33.5 months). Sub-pleural emphysematous changes were found in every histopathological specimen. In addition, 70.8% had fibrosis of visceral pleura. Recurrence occurred in 4 patients (2.2%). Ten-year freedom from recurrence was 96.2%. Procedure-related morbidity rate was 7.6%. Approximately 85.7% of patients were satisfied with the procedure and the cosmetic result. Three patients died during follow-up (1.6%).

CONCLUSIONS

Treatment of first episode of PSP by VATS is a safe procedure, with a very low rate of recurrence and a high patient satisfaction. This management of first episode of PSP is based on the underlying pathology. We recommend the use of VATS as the treatment of first choice for patients with PSP.

Needlescopic video-assisted thoracic surgery pleurodesis for primary pneumothorax

Conventional video-assisted thoracic surgery (VATS) is already well established as the approach of choice for definitive surgical management for primary pneumothorax. However, VATS itself is a constantly evolving technique. The needlescopic VATS (nVATS) approach uses the existing chest drain wound as a working port and adds only two 3-mm ports to provide equally effective pleurodesis as conventional VATS. Staple resection of bullae or blebs plus complete mechanical parietal pleural abrasion is achievable using nVATS. By potentially reducing morbidity for the individual patient, the nVATS approach may lower thresholds for surgical candidacy-even for first episodes of primary pneumothorax.

Technique for delivering large tumors in video-assisted thoracoscopic lobectomy

Background

The optimal technique for delivering large tumors during video-assisted thoracoscopic lobectomy remains uncertain.

Methods

In 258 patients receiving video-assisted thoracoscopic lobectomy for lung cancer, techniques for delivering the resected lobe included complete video-assisted thoracoscopic lobectomy without rib spreading ( n = 206, 80%), resection of a short rib segment ( n = 9, 3%), brief rib spreading ( n = 12, 5%), and conversion to a minithoracotomy ( n = 21, 8%). In 10 (4%) patients, a novel anterior rib cutting technique was used: one rib at the utility port was cut near its anterior end to widen the intercostal space without forcible rib spreading for lobe delivery.

Results

There was no mortality or major morbidity using the anterior rib cutting technique, and it delivered tumors of a larger mean diameter than complete video-assisted thoracoscopic lobectomy (5.4 ± 3.4 vs. 2.3 ± 1.4 cm, p = 0.017) whilst yielding a similar mean operation time and blood loss to the other non-complete video-assisted thoracoscopic lobectomy techniques. The anterior rib cutting technique gave similar postoperative patient pain scores and analgesic use to complete video-assisted thoracoscopic lobectomy, and shorter mean hospital stay than the other non-complete video-assisted thoracoscopic lobectomy techniques (5.6 ± 2.8 vs. 10.0 ± 7.1 days, p = 0.003).

Conclusions

In video-assisted thoracoscopic lobectomy, the anterior rib cutting technique is a safe and feasible procedure for delivering large tumors, causing no more pain than complete video-assisted thoracoscopic lobectomy, and allowing faster recovery than other non-complete video-assisted thoracoscopic lobectomy techniques.

Managing pain after thoracic surgery

SUMMARY It is generally accepted that thoracic surgery for lung cancer produces some of the most intense and difficult perioperative and chronic pain challenges. In the acute period of recovery, practitioners must optimize patient comfort and pulmonary function. This can be achieved through a combination of systemic treatment and regional analgesic options. Thoracic surgery also causes relatively high levels of persistent postsurgical pain. Many of the cases of persistent pain have a clear neuropathic pain mechanism, but a significant number of cases do not. While persistent pain correlates directly with the extent of operative trauma, even video-assisted thoracoscopic surgery approaches can cause chronic pain. Persistent pain is treated with medical and interventional therapies customized to an individual patient’s complaints and medication tolerance.

Feasibility of endoscopic transumbilical thoracic sympathectomy in a porcine model

OBJECTIVES

Thoracoscopic sympathectomy is an effective treatment for palmar hyperhidrosis. Current methods are associated with risks of chronic neuropathic pain and a visible chest scar. We developed a novel surgical technique for the performance of sympathectomy by embryonic natural orifice transumbilical endoscopic surgery with a flexible endoscope in a porcine model.

METHODS

Transumbilical flexible endoscopic thoracic sympathectomies were performed in seven farm pigs (three acute and four 4-week survivals). Under general anaesthesia, animals were intubated and mechanically ventilated with a dual lumen endotracheal tube through tracheostomy. A newly developed long transabdominal trocar was placed through the umbilicus. After insertion of a gastroscope through this trocar, a small incision was created on both sides of the diaphragm by a needle-knife. Then the gastroscope was inserted into the thoracic cavity, and the sympathetic chain was identified at the desired thoracic level and ablated. Operation time, safety and feasibility were recorded in all animals.

RESULTS

The transumbilical thoracic sympathectomies were successfully completed in all pigs with a mean operation time of 66.7 ± 9.4 min. Intraoperative bleeding occurred in one pig during the electrosurgical incision of diaphragm tissue, which was successfully controlled by hot biopsy forceps. No other acute intraoperative complications were observed in any cases. In the acute group, the length of the diaphragm incision ranged from 4 to 5 mm in three pigs. In the survival group, the animals recovered promptly from surgery. In three pigs, a small pneumothorax was found in the postoperative chest X-ray, but all of them were completely resolved with conservative treatment. Autopsy showed all bilateral T3 sympathetic chains were successfully ablated and no evidence of vital structure injury or diaphragmatic hernia.

CONCLUSIONS

Transumbilical flexible endoscopic thoracic sympathectomy is technically feasible, simple and safe in a porcine model. This technique can be used as a novel experimental platform for studies of natural orifice transluminal endoscopic surgery (NOTES) for intrathoracic surgery.

Evidence-based review of the surgical management of hyperhidrosis

The great majority of the currently available evidence supporting sympathectomy for primary hyperhidrosis is observational, coming from a variety of prospective and restrospective clinical series as well as comparative studies. A cumulative experience in over 6000 patients suggests that ETS is a safe, reproducible, and effective procedure, and most patients are satisfied with the results of the surgery. The currently available experimental data comes from clinical trials that compared alternative levels of sympathetic chain disruption; these trials speak only to the relative merits of one surgical technique over another and do not provide an assessment of the overall impact of surgery in the general population of patients with primary hyperhidrosis. Furthermore, it is difficult to compare series and generalizability is compromised by a lack of uniform definitions and measures at both the exposure and outcome levels. There is marked heterogeneity with respect to study population and entry criteria, with significant variability of site and severity of excess sweating as well as the degree of preoperative conservative management of hyperhidrosis before surgical referral. Also the operative approach varies widely among studies, and the optimal procedure remains elusive: unilateral versus staged nonsimultaneous bilateral versus concomitant bilateral sympathectomy; ganglionic resection versus ablation using electrocoagulation or harmonic scalpel; clipping of the chain to maintain reversibility in the event of intolerable symptoms versus permanent disruption. In addition, the lack of uniform outcome measures makes these data difficult to interpret, and standardized metrics of surgical results are necessary, such as objective quantification of sweating by gravimetry or use of the SF-36 Health Survey Questionnaire as an estimate of patient quality of life. A multicenter, adequately powered, randomized controlled trial comparing surgical to medical management of hyperhidrosis is unlikely given the current enthusiasm for same-day thoracoscopic sympathectomy among surgeons, a largely positive literature replete with encouraging results, and well-informed hyperhidrosis patients who want to be cured of a socially debilitating illness. Future clinical trials in this area will likely compare surgical techniques. For such comparisons, procedures must be standardized and outcome measures validated for both symptoms of the disease and surgical complications. Finally, the studies must have large numbers of patients and adequate long-term follow-up if they are to detect differences in results among procedures with very high technical success rates.