Assessment and follow-up of intercostal nerve damage after video-assisted thoracic surgery

Evolution of Video Assisted Thoracoscopic Surgery for Thoracic Disc Herniation: Towards Biportal Thoracoscopic Approach

OBJECTIVE

This work aims to describe the evolution of the video-assisted Thoracoscopic Surgery (VATS) approach from a multiportal access to a biportal access for thoracic herniated disc surgery. Thoracic disc herniation remains a challenging pathology for spine surgeons. VATS of the thoracic spine was described in the 90s and represented an important technical leap by including minimally invasive options for thoracic pathology. Nowadays, VATS in thoracic surgery tends to evolve towards an even less invasive technique, from a multiportal approach to a biportal one.

METHODS

We describe the adoption of this approach for our spinal pathology in 3 patients. We use a two-port VATS. The largest (approximately 5 cm) with an Alexis retractor and a second port (1.5 cm) just for the camera.

RESULTS

The 3 patients started walking in less than 24 hours and none suffered any complications related to the approach. All of them reported tolerable pain at the surgical site. Changing our previous VATS system from 3 to 5 ports was relatively easy regarding the surgical technique.

CONCLUSIONS

This access allows the surgeon to manipulate the instrumentation confidently and the camera does not fog up as often. Extracting a piece of rib is unnecessary and theoretically, we only manipulate 1 or at most 2 intercostal nerves, so the patient's recovery is favorable.

Uniportal video-assisted thoracic surgery versus open thoracotomy for chronic pain after surgery: a prospective cohort study

PURPOSE

The potential of uniportal video-assisted thoracic surgery (U-VATS) to reduce chronic pain after thoracic surgery (CPTS) compared to open thoracotomy (OT) remains unexplored. This prospective study aims to assess the incidence of CPTS following U-VATS or OT and identify associated risk factors.

METHODS

Patients undergoing thoracic surgery were recruited from March 2021 to March 2022, categorized by surgical approach (U-VATS vs. OT). Standard clinical protocols for surgery, anesthesia, and analgesia were followed. Pain symptoms were assessed using the Short-form McGill Pain Questionnaire, with follow-ups up to 6 months. Perioperative factors influencing CPTS at 3 months were analyzed through univariate and multivariate methods.

RESULTS

A total of 694 patients were analyzed. Acute pain after thoracic surgery (APTS) was significantly less severe in the U-VATS group (p < 0.001). U-VATS patients exhibited a lower incidence of CPTS at 3 months (63.4% vs. 80.1%, p < 0.001), with reduced severity among those experiencing CPTS (p = 0.007) and a decreased occurrence of neuropathic pain (p = 0.014). Multivariate analysis identified OT incision, moderate to severe APTS (excluding moderate static pain at 24 h postoperative), nocturnal surgery, and lung surgery as risk factors for CPTS.

CONCLUSION

This study underscores the potential of U-VATS to reduce both the incidence and severity of CPTS at 3 months compared to OT. Furthermore, it highlights risk factors for CPTS, including OT incision, inadequately managed APTS, lung surgery, and nocturnal surgery. These findings emphasize the importance of considering surgical approach and perioperative pain management strategies to mitigate the burden of CPTS.

Greater ipsilateral rectus muscle atrophy after robotic thoracic surgery compared with open and video-assisted thoracoscopic surgery approaches

Objective

Robotic thoracic surgery provides another minimally invasive approach in addition to video-assisted thoracoscopic surgery (VATS) that yields less pain and faster recovery compared with open surgery. However, robotic incisions are generally placed more inferiorly, which may increase the risk of intercostal nerve injury that affects the abdominal wall. We hypothesized that a robotic approach causes greater ipsilateral rectus muscle atrophy compared with open and VATS approaches.

Methods

The cross-sectional area and density of bilateral rectus abdominis muscles were measured on computed tomography scans in patients who underwent lobectomy in 2018. The differences between the contralateral and ipsilateral muscles were compared between preoperative and 6-month surveillance scans. Changes were compared among the open, VATS, and robotic approaches through a mixed effects model after adjustments of correlation and covariates.

Results

Of 99 lobectomies, 25 (25.3%) were open, 56 (56.6%) VATS, and 18 (18.1%) robotic. The difference between the contralateral and ipsilateral rectus muscle cross-sectional area was significantly larger at 6 months after robotic surgery compared with open (31.4% vs 9.5%, P = .049) and VATS (31.4% vs 14.1%, P = .021). There were no significant differences in the cross-sectional area between the open and VATS approach.

Conclusions

In this retrospective analysis, there was greater ipsilateral rectus muscle atrophy associated with robotic thoracic surgery compared with open or VATS approaches. These findings should be correlated with clinical symptoms and followed to assess for resolution or persistence.

Efficacy and safety of add-on mirogabalin to conventional therapy for the treatment of peripheral neuropathic pain after thoracic surgery: the multicenter, randomized, open-label ADMIT-NeP study

BACKGROUND

For chronic pain after thoracic surgery, optimal timing of its diagnosis and effective treatment remains unresolved, although several treatment options are currently available. We examined the efficacy and safety of mirogabalin, in combination with conventional pain therapy (nonsteroidal anti-inflammatory drugs and/or acetaminophen), for treating peripheral neuropathic pain (NeP) after thoracic surgery.

METHODS

In this multicenter, randomized, open-label, parallel-group study, patients with peripheral NeP were randomly assigned 1:1 to mirogabalin as add-on to conventional therapy or conventional treatment alone.

RESULTS

Of 131 patients of consent obtained, 128 were randomized (mirogabalin add-on group, 63 patients; conventional treatment group, 65 patients). The least squares mean changes (95% confidence interval [CI]) in Visual Analogue Scale (VAS) score for pain intensity at rest from baseline to Week 8 (primary endpoint) were - 51.3 (- 54.9, - 47.7) mm in the mirogabalin add-on group and - 47.7 (- 51.2, - 44.2) mm in the conventional group (between-group difference: - 3.6 [95% CI: - 8.7, 1.5], P = 0.161). However, in patients with Self-administered Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS) score (used for the screening of NeP) ≥ 12 at baseline, the greater the S-LANSS score at baseline, the greater the decrease in VAS score in the mirogabalin add-on group, while no such trend was observed in the conventional treatment group (post hoc analysis). This between-group difference in trends was statistically significant (interaction P value = 0.014). Chronic pain was recorded in 7.9% vs. 16.9% of patients (P = 0.171) at Week 12 in the mirogabalin add-on vs. conventional treatment groups, respectively. Regarding activities of daily living (ADL) and quality of life (QOL), changes in Pain Disability Assessment Scale score and the EQ-5D-5L index value from baseline to Week 8 showed significant improvement in the mirogabalin add-on group vs. conventional treatment group (P < 0.001). The most common adverse events (AEs) in the mirogabalin add-on group were dizziness (12.7%), somnolence (7.9%), and urticaria (3.2%). Most AEs were mild or moderate in severity.

CONCLUSIONS

Addition of mirogabalin to conventional therapy did not result in significant improvement in pain intensity based on VAS scores, but did result in significant improvement in ADL and QOL in patients with peripheral NeP after thoracic surgery.

TRIAL REGISTRATION

Japan Registry of Clinical Trials jRCTs071200053 (registered 17/11/2020).

Quantitative Sensory Changes Following Posterior Spinal Fusion to Treat Adolescent Idiopathic Scoliosis

BACKGROUND

Sensory changes surrounding the incision frequently develop after posterior spinal fusion (PSF) to treat adolescent idiopathic scoliosis (AIS). Anecdotally, patients may experience sensory changes on the chest wall. Such postsurgical sensory changes are not well described quantitatively. This study aims to evaluate the presence, intensity, and duration of mechanical sensory changes in AIS patients postoperatively.

METHODS

A prospective cohort of AIS patients, 10 to 21 years old, was followed. Quantitative sensory testing (QST) included touch detection threshold [mechanical detection threshold (MDT)] and pain detection threshold (MPT), using VonFrey monofilaments and pinprick stimulators. QST was performed at 3 sites at T6: the right and left chest at the nipple line and adjacent to the incision below the inferior angle of the scapula. QST at the thenar eminence was the control. QST was collected at baseline, 3 days, 1, and 6 months postoperative.

RESULTS

Thirty-four patients (21% males; mean age: 14.9 years old; median preoperative curve: 58 degrees) completed all testing. Mean deformity correction was 64% (SD: 10.4). Adjacent to the incision site, MDT was significantly higher compared with baseline at 3 days and 1 month ( P < 0.001) but not at 6 months ( P = 0.19), whereas MPT was significantly higher at 3 days, ( P < 0.001), 1 month ( P < 0.001), and 6 months ( P = 0.001). For the chest wall in all patients, MPT was higher on the left chest at 3 days ( P = 0.04) and on the right chest at 3 days ( P = 0.022) and 1 month ( P = 0.05). For patients with right-sided curves, MDT ( P = 0.01) and MPT ( P = 0.015) overall were significantly higher on the concave side (left) chest postoperatively.

CONCLUSIONS

PSF is associated with sensory disturbances that are detectable within days, persist at 1 month, and improve at 6 months postoperatively adjacent to the incision and on the chest wall. We suspect that these sensory changes are transient. Describing postoperative sensory changes will help us better set postoperative expectations for patients undergoing PSF.

LEVEL OF EVIDENCE

Level I.

A propensity sore-matched study: Applying a modified chest tube drainage strategy in rapid rehabilitation following uni-portal thoracoscopic pulmonary wedge resection

PURPOSE

This study aimed to compare the value of a modified chest tube drainage strategy to a traditional drainage strategy in single-port thoracoscopic pulmonary wedge resection.

METHODS

From January 2019 to July 2021, we collected clinical data on 405 patients who underwent single-port thoracoscopic pulmonary wedge resection in the No.1 Department of Thoracic Surgery at Fujian Medical University Union Hospital, with 121 (29.9%) cases in the modified drainage strategy group and 284 (70.1%) cases in the traditional drainage strategy group. The propensity score matching method (Match Ratio = 1:1) was used to reduce differences in clinical characteristics between the two groups.

RESULTS

Following 1:1 propensity score matching, 120 matched pairs (240 patients) were included in the study. There was no significant difference in general clinical characteristics between the two groups. There was no statistical difference in intraoperative factors except for operative times (71.42 ± 22.98 min vs. 86.80 ± 36.75 min, p < 0.001). In terms of postoperative factors, there were significant differences in postoperative chest tube duration (0.00 ± 0.00 h vs. 32.68 ± 18.51 h, p < 0.001), total drainage volume (143.03 ± 118.33 ml vs. 187.73 ± 140.82 ml, p = 0.008), postoperative hospital stay (2.61 ± 0.70 days vs. 3.27 ± 1.88 days, p < 0.001), number of additional pain relief (0.14 ± 0.40 vs. 0.42 ± 0.74, p < 0.001), facial pain score (2.7 ± 1.8 vs. 3.6 ± 2.7, p = 0.005) and adverse events (p = 0.046). Furthermore, there was a statistical difference between the two groups regarding CTCAE grade-1 complication, but no statistical difference in CTCAE grade-2 complication.

CONCLUSIONS

A modified drainage strategy in single-port thoracoscopic pulmonary wedge resection is safe and feasible, allowing for less postoperative rehabilitation time, pain relief, reduced postoperative pleural effusion, and reduced clinical workload.

Simultaneous Comparison of Subxiphoid and Intercostal Wound Pain in the Same Patients Following Thoracoscopic Surgery

There is a lack of data comparing postoperative pain after subxiphoid and intercostal video-assisted thoracoscopic surgery (VATS). Pain is an individual’s subjective experience and, therefore, difficult to compare between different individuals subjected to either procedure. This study assessed reported pain at six postoperative time points in the same patients receiving both subxiphoid and intercostal incisions for thoracic disease. Data from 44 patients who received simultaneous combined intercostal and subxiphoid VATS were retrospectively analyzed from August 2019 to July 2021. All patients received the same length of subxiphoid and intercostal incisions with or without drain placements. A numerical pain rating scale was administered on postoperative days (POD)-1, POD-2, POD-Discharge, POD-30, POD-90, and POD-180. Bilateral uniportal VATS was performed in 11 patients, and unilateral multiportal VATS was performed in 33 patients. In the unilateral VATS group, there were no differences in pain reported for both incisions in the early postoperative period. However, in the bilateral VATS group, subxiphoid wounds resulted in significantly higher pain scores on POD-1, POD-2, and POD-Discharge (p = 0.0003, 0.001, and 0.03, respectively). Higher late (3 and 6 months) postoperative pain was associated with intercostal incisions in both groups, as previously reported, whereas higher early (day 1, 2, and discharge) postoperative pain was more associated with subxiphoid incisions than intercostal incisions in the bilateral VATS group.

Safety and feasibility study of uniportal video-assisted thoracoscopic pulmonary wedge resection without postoperative chest tube drainage: a retrospective propensity score-matched study

OBJECTIVES

The aim of this study was to assess the impact of postoperative chest tube drainage (CTD) on safety and postoperative recovery by comparing patients with pulmonary nodule undergoing uniportal video-assisted thoracoscopic pulmonary wedge resection with and without postoperative CTD.

METHODS

We retrospectively analysed the data of patients who underwent video-assisted thoracoscopic pulmonary wedge resection for pulmonary nodule at our hospital between 2018 and 2022. In cases where a 12-Fr chest tube was used following the procedure, the tube was not usually removed until the day after surgery. Therefore, the eligible patients were categorized into the drainage tube or the no-drainage tube group according to the use of postoperative CTD. Propensity score matching at a ratio of 1:1 was performed using clinicopathologic and demographic variables. The highest postoperative pain score, postoperative complication rate, postoperative length of stay and hospitalization costs were compared between the 2 groups.

RESULTS

A total of 275 eligible patients, including 150 and 125 patients in the drainage tube and no-drainage tube groups, respectively, were included in the study. After propensity score matching, there were 102 patients in each group. The postoperative complication rate during hospitalization and at 1 week and 1 month after discharge were not significantly different between the 2 groups (P > 0.05 for all). The highest postoperative pain score was significantly lower in the no-drainage tube group than in the drainage tube group [2.02 (standard deviation: 0.81) days vs 2.31 (standard deviation: 0.76) days, P = 0.008]. The postoperative length of stay was significantly shorter in the no-drainage tube group than in the drainage tube group {3.00 [interquartile ranges (IQRs): 2.00-4.00] days vs 2.00 (IQRs: 1.00-3.00) days, P < 0.001}. Similarly, the total hospitalization costs were significantly lower in the no-drainage tube group than in the drainage tube group [33283.74 (IQRs: 27098.61-46718.56) yuan vs 26598.67 (IQRs: 22965.14-29933.67) yuan, P < 0.001].

CONCLUSIONS

Omission of postoperative CTD was safe and feasible in patients with pulmonary nodule undergoing wedge resection. The no-postoperative-drainage policy can substantially shorten the length of hospital stay and reduce the postoperative pain and hospitalization costs without increasing the risk of postoperative complications.

Mirogabalin treatment of postoperative neuropathic pain after thoracic surgery: study protocol for a multicenter, randomized, open-label, parallel-group, interventional trial

Background

Intercostal nerve damage due to thoracotomy or thoracoscopic manipulation is a major contributor to chronic postsurgical pain after pulmonary resection. Chronic postsurgical pain may last for months or years and can negatively impair physical functioning and daily activities. Global consensus on severe postoperative pain management is lacking, and chronic pain incidence after thoracic surgery remains high. Many patients report neuropathic pain, which can be difficult to treat with currently available therapies. The efficacy and safety of mirogabalin have been demonstrated for other types of neuropathic pain; thus, this study was planned to investigate the efficacy and safety of mirogabalin to treat neuropathic pain after thoracic surgery.

Methods

In this multicenter, randomized, open-label, parallel-group, interventional study, patients who are diagnosed with neuropathic pain following removal of a chest drain after lung resection will receive conventional therapy (non-steroidal anti-inflammatory drugs and/or acetaminophen) with or without the addition of a clinical dose of mirogabalin for 8 weeks. For patient stratification, a visual analog scale pain intensity score at baseline of <60 vs. ≥60 mm will be used. Treatment efficacy and safety with and without the addition of mirogabalin will be assessed using a questionnaire evaluating postoperative changes in pain severity and activity. The primary study endpoint is the change in pain intensity from baseline to Week 8, measured by the visual analog scale. Additionally, the presence of chronic pain at 12 weeks after enrollment in each treatment group will be recorded.

Discussion

This protocol has been reviewed and approved by the Clinical Research Review Board of Nagasaki University. Study data will be published in the Japan Registry of Clinical Trials database and peer-reviewed journals. Mirogabalin is already approved for the treatment of other types of neuropathic pain. It is anticipated that this study will provide data to elucidate the impact of mirogabalin treatment, in combination with conventional therapy, to benefit patients with neuropathic pain following thoracic surgery.

Trial Registration

Japan Registry of Clinical Trials Identifier: jRCTs071200053.

Subxiphoid versus intercostal video-assisted thoracic surgery for lung resection: a meta-analysis

INTRODUCTION

To systematically evaluate the safety and advantages of subxiphoid approach video-assisted thoracic surgery (SA-VATS) compared with intercostal approach video-assisted thoracic surgery (IA-VATS) for lung resection, we conducted a meta-analysis of the current literature.

MATERIAL AND METHODS

The literature search was conducted in PubMed, Web of Science, Cochrane Library, Embase, and China National Knowledge Infrastructure. RevMan 5.3 software was used to perform this meta-analysis.

RESULTS

Eleven studies involving 934 patients were included. Compared with patients in the IA-VATS group, those in the SA-VATS group had lower pain scores on the day of the operation and at 24 h, 48 h and 72 h after the operation (p < .001) and suffered from less postoperative paraesthesia at the first, third and sixth months after the operation (p < .001). Moreover, there was no statistically significant difference between the two groups regarding postoperative complications, intraoperative blood loss, length of hospital stay, drainage amount, or chest tube duration. However, SA-VATS had a longer operative time (p < .001).

CONCLUSIONS

SA-VATS is a safe surgical technique and has superior postoperative outcomes over IA-VATS for lung resection in terms of acute postoperative pain and chronic postoperative paraesthesia.

Pain and Opioid Use After Thoracic Surgery: Where We Are and Where We Need To Go

As many as one third of patients undergoing minimally invasive thoracic surgery and one half undergoing thoracotomy will have chronic pain, defined as pain lasting 2 to 3 months. There is limited information regarding predictors of chronic pain and even less is known about its impact on health-related quality of life, known as pain interference. Currently, there is a focus on decreased opioid prescribing after surgery. Interestingly, thoracic surgical patients are the least likely to be receiving opioids before surgery and have the highest rate of new persistent opioid use after surgery compared with other surgical cohorts. These studies of opioid use have identified important predictors of new persistent opioid use, but their findings are limited by failing to correlate opioid use with pain. The objectives of this invited review are to present the findings of pertinent studies of chronic pain and opioid use after thoracic surgery, "where we are," and to discuss gaps in our knowledge of these topics and opportunities for research to fill those gaps, "where we need to go."

Does the length of uniportal video-assisted thoracoscopic lobectomy affect postoperative pain? Results of a randomized controlled trial

BACKGROUND

Uniportal video-assisted thoracoscopic surgery (VATS) lobectomy has become a common approach for the treatment of early stage lung cancer. Here, we aimed to establish whether the length of uniportal incision could affect postoperative pain and surgical outcomes in consecutive patients undergoing uniportal VATS lobectomy for early stage lung cancer.

METHODS

This was a unicenter Randomized Control Trial (NCT03218098). Consecutive patients undergoing uniportal VATS lobectomy for Stage I lung cancer were randomly assigned to a Small Incision group or Long Incision group in 1:1 ratio based on whether patients received a 4 cm or 8 cm incision. The endpoints were to compare the intergroup difference regarding (i) postoperative pain measured by brief pain inventory (BPI) questionnaire (first endpoint); (ii) operative time; (iii) length of chest drainage; (iv) length of hospital stay; (v) postoperative complications; and (vi) pulmonary functional status (secondary endpoints).

RESULTS

A total of 48 patients were eligible for the study. Four patients were excluded; the study population included 44 patients: 23 within the Small Incision group, and 21 within the Long Incision group. The 11 BPI scores between the two groups showed no significant difference. Small Incision group presented higher operative time than Long Incision group (138.69 vs. 112.14 minutes; P = 0.0001) while no significant differences were found regarding length of hospital stay (P = 0.95); respiratory complications (P = 0.92); FEV1% (P = 0.63), and 6-Minute Walking Test (P = 0.77).

CONCLUSIONS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome.

KEY POINTS

A larger incision for uniportal VATS lobectomy significantly reduced the operative time due to better exposure of the anatomical structures without increasing postoperative pain or affecting the surgical outcome. To perform a larger incision could be a valuable strategy, particularly in nonexpert hands or when the patient's anatomy or tumor size make exposure of anatomic structures through smaller incisions difficult.

Video-assisted thoracoscopic surgery for ectopic mediastinal parathyroid tumor: subxiphoid and lateral thoracic approach

Background

This study aimed to investigate the initial results of an endoscopic surgical approach for the treatment of intramediastinal ectopic parathyroid adenoma and to evaluate the effectiveness of a single-incision resection using the subxiphoid approach.

Methods

Five cases of patients (1.89%) were diagnosed with ectopic mediastinal parathyroid tumor and underwent resection from 2008 to 2017 in Fujita Health University Hospital. They were retrospectively analyzed.

Results

Four patients underwent single-port mediastinal tumor resection using the subxiphoid approach and 1 patient underwent multi-port mediastinal tumor resection using the lateral thoracic approach. The operation time was 134±83.52 min, and the amount of blood loss was 81.8±173.41 mL. The rate of conversion to thoracotomy was 0%, and no intraoperative or postoperative complications were observed. The amount of postoperative oral analgesics was 112.83±209.12 tablets, and their administration period was 561.6±1,229.5 days. The length of hospital stay was 4±2.35 days, and the duration of chest tube drainage was 1.33±1.95 days. The patient who underwent multi-port mediastinal tumor resection using the lateral thoracic approach reported postoperative pain. Serum calcium levels decreased from 10.56±1.52 mg/dL preoperatively to 8.96±0.5 mg/dL postoperatively, and serum phosphorous levels increased from 2.84±0.42 mg/dL preoperatively to 3.6±0.51 mg/dL postoperatively. Intact-PTH hormone levels decreased from 221±169.84 pg/dL preoperatively to 70.2±44.28 pg/dL postoperatively. No recurrence of hyperparathyroidism has been observed in any patient.

Conclusions

The single-incision mediastinal tumor resection via the subxiphoid approach, without going through the intercostal space, is considered as a useful endoscopic surgical approach for the treatment of mediastinal ectopic parathyroid adenomas due to the limited occurrence of post-thoracotomy pain syndrome and the superior esthetic outcomes associated with the procedure as compared to thoracotomy and median sternotomy.

Comparison of the perioperative outcomes in antero-superior mediastinal tumor resection performed by transcervical resection and video-assisted thoracoscopic surgery

Background

It remains controversial that whether transcervical resection (TC) was associated with better outcomes than video-assisted thoracoscopic surgery (VATS) in the treatment of antero-superior mediastinal tumors. We aimed to compare the safety and reliability between TC and VATS.

Methods

Between 2010 and 2012, 80 consecutive patients underwent antero-superior mediastinal tumor resection via TC (n=31) or VATS (n=49). Perioperative outcomes were compared. A propensity score-matched analysis was performed to control the potential confounders.

Results

A total of 41 men and 39 women with median age of 52.5 years were enrolled. No patient died during the perioperative course. After propensity matching, TC group was associated with less intraoperative blood loss (35.1±18.7 vs. 93.7±136.1 mL, P=0.034), less postoperative drainage (65.6±76.8 vs. 335.0±154.9 mL, P<0.001), shorter length of postoperative hospital stay (3.2±1.2 vs. 4.1±1.3 days, P=0.003) and less hospitalization expense (22,252.3±4,761.7 vs. 26,514.2±4,052.8 CNY, P=0.002) compared to VATS group. One patient with VATS was converted to open surgery due to intraoperative vessels damage. The postoperative complication was null in TC group while it was 6.1% (n=3) in VATS group (P=0.279), including 1 case of prolonged chest tube drainage and 2 cases of recurrent laryngeal nerve injury.

Conclusions

TC for antero-superior mediastinal tumors is a safe procedure with better perioperative outcomes compared to VATS.

Chronic pain after bilateral thoracotomy in lung transplant patients

Background and aims

The relative contribution of patient-related factors and intraoperative nerve damage for the development of chronic pain after surgery is unclear. This study aimed to examine chronic pain after bilateral thoracotomy. We hypothesized, that individual patient-related risk factors would be important resulting in an intraindividual uniformity of pain and hyperphenomena between the two sides of the thorax.

Methods

Twenty patients who had undergone lung transplantation via bilateral thoracotomy 6–12 months previously were included from the Danish Lung Transplant program, Rigshospitalet, Denmark, from October 2016 to August 2017. All patients answered questionnaires about pain in and around the scar, completed the Neuropathic Pain Symptom Inventory, and underwent bedside examination for hyperphenomena (brush- and cold-evoked allodynia, pinprick hyperalgesia) and pinprick hypoalgesia.

Results

Nine patients reported spontaneous pain bilaterally, five patients had pain on one side only, and six patients had no pain. Hyperphenomena were present on both sides of the thorax in 13 patients, on one side in four patients, and three patients had no hyperphenomena. The intraindividual uniformity of pain (p=0.029) and hyperphenomena (p=0.011) between the two sides of the thorax suggests that patient-related factors play an important role in the development of chronic pain.

Conclusions

The results of the present study provide support for the hypothesis of an individual predisposition for the development of chronic pain after thoracotomy.

Implications

Patient-related risk factors contribute to the development of chronic pain after thoracotomy. This result most likely can be transferred to chronic pain after other surgical procedures and therefore help us understand risk factors for chronic pain after surgery.

From acute to chronic pain after thoracic surgery: the significance of different components of the acute pain response

Purpose

Acute postoperative pain is a strong predictor for postthoracotomy pain syndrome (PTPS), but the mechanism is unknown. Even though thoracic pain is usually considered the dominating acute pain after thoracic surgery, up to 45% of patients consider shoulder pain to be dominating pain and often this shoulder pain is referred visceral pain. This study aims to examine which components of the acute pain response after thoracic surgery were associated with PTPS and if any signs of a generalized central hypersensitivity could be identified in patients with PTPS.

Patients and methods

In a prospective cohort study, 60 consecutive patients for lobectomy were included and examined preoperatively and 12 months postoperatively for pain and signs of hypersensitivity using a comprehensive protocol for quantitative sensory testing. Thoracic pain, shoulder pain, referred pain, and overall pain were assessed five times daily during the first four postoperative days.

Results

Sixteen patients (31% of the 52 patients who completed the study) developed PTPS. Thoracic pain was the only pain component that was associated with PTPS and was a stronger predictor for PTPS than overall pain. There were no signs of hypersensitivity before or after the operation in patients with PTPS, but patients with PTPS more often suffered from preoperative pain.

Conclusion

Thoracic pain was the only component of the acute pain response that predicted PTPS and was a stronger predictor than overall pain.

The influence of the trocar choice on post-operative acute pain after thoracoscopy

Background

Acute post-operative pain following thoracic surgery procedures is still an unresolved problem despite the introduction of minimally invasive procedures such as video assisted surgery. Until now it is never investigated if different surgical instruments could influence post-operative pain. The aim of our study is to investigate the role of different type of trocar on post-operative pain in minimally invasive thoracic surgery.

Methods

This was a prospective randomized single center study. We identified 53 patients randomized into three groups underwent single port thoracoscopy for malignant pleural effusion with drainage of the fluid and talc poudrage. The three groups differ for the trocar type, rigid, flexible and wound protector.

Results

We compared the postoperative pain between the three groups in which there was no statistical difference. Rigid trocar seems to give a more stable level of pain during the days, flexible trocar gains more pain in the first few hours, however the pain at discharge decreases significantly, reaching the similar values, in all the three groups. The association between pain at discharge and operative time or days of drainage was analyzed by means of linear regression, no statistically significant difference was found.

Conclusions

Our study showed that different type of trocars during video assisted thoracic surgery (VATS) produces similar level of acute postoperative pain. In future, further randomized study with a great number of patients enrolled needs to confirm our results.

Electro-physiological evidence of intercostal nerve injury after thoracotomy: an experimental study in a sheep model

BACKGROUND

Although intercostal nerve injury is one of the major causes for post-thoracotomy pain, the exact mechanisms are still unclear. We sought to evaluate the electro-physiological changes of intercostal nerve injury after thoracotomy in a sheep model.

METHODS

Adult sheep underwent thoracotomy in the sixth intercostal space by employing diathermy to superior border of the seventh rib. In two sheep, ribs were then spread using retractor spreading for a distance of 7 cm for 30 minutes. In the third sheep, thoracotomy was followed by harvesting intercostal muscles including the neurovascular bundle adjacent to inferior edge of the sixth rib. Thereafter, ribs were spread in the same way, but with the muscle flap dangled between the blades for intercostal nerve protection (dangling muscle flap technique). The nerve conduction velocity of the intercostal nerve was recorded before and after incision of intercostal muscles, immediately and 30 minutes after retractor placement and 30 minutes after removal of the retractor.

RESULTS

In the sheep undergoing conventional thoracotomy, the physiological conductivity of intercostal nerve was completely blocked immediately after retractor placement using the same stimulation intensity or even the supra-threshold intensity. The conduction block persisted for 30 minutes during the retractor placement and further 30 minutes after removal of the retractor. In contrast, intercostal nerve conduction was not impaired throughout the experiment with the dangling muscle flap technique.

CONCLUSIONS

Our experiment provides electro-physiological evidence for intercostal nerve injury after thoracotomy. The injury is primarily attributed to mechanical compression caused by the rib retractor.

Rib Composite Flap With Intercostal Nerve and Internal Thoracic Vessels for Mandibular Reconstruction

Purpose:

The purpose of this study was to present the outcome and discuss the feasibility of rib composite flap with intercostal nerve and internal thoracic vessels for reconstructing mandibular defect.

Methods:

Rib composite flaps have been used in 82 patients for reconstructing benign tumor-caused large mandibular defects: 66 of the 82 patients were reconstructed using rib composite flap with intercostal nerve and internal thoracic vessels, whereas the other 16 patients were reconstructed using rib composite flap with internal thoracic vessels, without intercostal nerve. After operation, clinical observation, imageological examination, and sensory detection were used to evaluate the effect of reconstruction.

Results:

All rib composite flaps with intercostal nerve and internal thoracic vessels were successfully harvested and transplanted. Both immediate and long-term examination showed good appearance reconstruction. All followed-up patients conveyed good satisfaction degree with function and appearance reconstruction. Postoperative panoramic x-ray examination showed new bone formation between the transplanted rib and mandibular stump. Good recoveries of mandibular nerve sensory were observed when followed up after reconstruction surgery.

Conclusions:

Rib composite flap with intercostal nerve and internal thoracic vessels could be a promising method for reconstruction of mandibular defects.

Outcomes of Totally Endoscopic Atrial Septal Defect Closure Using a Glutaraldehyde-Treated Autologous Pericardial Patch

BACKGROUND

We evaluated the outcomes of totally endoscopic minimally invasive surgery for atrial septal defect (ASD) using a glutaraldehyde-treated autologous pericardial patch in the transcatheter interventional era.Methods and Results:We retrospectively reviewed 37 consecutive patients who underwent totally endoscopic ASD closure with a glutaraldehyde-treated autologous pericardial patch between June 2011 and April 2015. All patients had been deferred from catheter-based intervention for clinical or anatomical reasons. We analyzed operative outcomes and postoperative echocardiographic data. The mean age was 45.7±16.5 years, and 25 patients (67.6%) were women. The mean ratio of pulmonary to systemic flow was 2.4±0.7. Six patients (16.2%) underwent concomitant tricuspid valve repair, and 3 patients (8.1%) underwent concomitant atrial fibrillation surgery. There were no operative deaths, and the median length of hospital stay was 5 days. Postoperative echocardiography revealed trivial residual shunt in 1 patient. During the follow-up period, there were no re-interventions for ASD or readmission for heart failure. Follow-up echocardiography revealed no recurrent shunt or calcification of the autologous pericardial patch.

CONCLUSIONS

Totally endoscopic ASD closure with a glutaraldehyde-treated autologous pericardial patch demonstrated excellent outcomes. It is a useful option for patients with unfavorable anatomy or other reasons excluding transcatheter intervention.

Is early postoperative administration of pregabalin beneficial for patients with lung cancer?-randomized control trial

BACKGROUND

Post-thoracotomy pain is an obstacle for lung-cancer patients even after introduction of less invasive surgical procedures. The aim of this prospective study was to evaluate if early postoperative administration of pregabalin is beneficial for patients with non-small cell lung cancer (NSCLC).

METHODS

We conducted a randomized open control trial. Patients with NSCLC were allocated randomly to epidural and nonsteroidal anti-inflammatory drug (NSAID) use for analgesia (control group) or pregabalin use (pregabalin group). Primary endpoint was the frequency of additional administration of a NSAID. Secondary endpoints were intensity of ongoing pain, frequency of neuropathic pain, and pain catastrophizing.

RESULTS

Seventy-two patients were registered and allocated. Thirty-four cases in the control group and 33 in the pregabalin group were assessed. Age, sex, body mass index (BMI), type of surgical procedure, type of lymph-node dissection, operation time, bleeding, duration of chest-tube insertion, and postoperative hospital stay between the two groups was not significantly different. Frequency of additional NSAID use between the control group (2±4 suppositories) and pregabalin group (2±3 suppositories) was not significantly different (P=0.62). Numeric Rating Scale (NRS) for the intensity of ongoing pain, frequency of neuropathic pain, and Pain Catastrophizing Scale (PCS) between each group were not significantly different at any time until 3 months after surgery.

CONCLUSIONS

Early postoperative administration of pregabalin is not beneficial for patients with NSCLC.

Ratio of C-reactive protein to albumin is a prognostic factor for operable non-small-cell lung cancer in elderly patients

PURPOSE

The aim of this retrospective study was to evaluate inflammation-based scoring as a prognostic factor for operable non-small-cell lung cancer (NSCLC) in elderly patients.

METHODS

We collected preoperative data from 108 patients aged above 80 years with NSCLC. Inflammation-based scoring systems, including the C-reactive protein to albumin ratio (CAR) and the Glasgow prognostic score (GPS), as well as other clinicopathological factors, were evaluated as potential prognostic factors.

RESULTS

The median patient age was 82 (range 80-93) years and the 5-year overall and disease-specific survival rates were 49.7 and 73.9%, respectively. The cut-off value for CAR was calculated using a receiver operator characteristics analysis and patients were dichotomized accordingly. Patients with a low CAR had significantly higher overall survival than those with a high CAR (<0.028; 65.2% vs. ≥0.028; 31.0%, respectively; p < 0.01). In univariate analysis, female gender, a low Charlson comorbidity index of 0 or 1 and a low CAR were significantly identified in overall survival. On multivariate analysis, a low CAR (p = 0.03, hazard ratio: 2.13, 95% confidence interval 1.074-4.295) was identified as a significant prognostic factor.

CONCLUSIONS

The preoperative CAR is a useful predictor of overall survival and could be a simple prognostic tool to help identify resectable NSCLC in elderly patients.

Persistent postsurgical pain after video-assisted thoracic surgery--an observational study

BACKGROUND

The risk of persistent postsurgical pain (PPP) and subsequent pain-related functional impairment may potentially be reduced by video-assisted thoracic surgery (VATS) compared to thoracotomy. The aim of the study was therefore to assess in detail the incidence and consequences on activities of daily living of PPP after VATS.

METHODS

Using a prospective observational design, 47 patients undergoing VATS completed both preoperative, early postoperative and 3 months follow-up. Preoperative pain, pain characteristics, psychological factors, pain-related functional impairment and quantitative sensory testing (QST) including nociceptive thresholds were compared with postoperative data.

RESULTS

Only five (11%) patients developed PPP with NRS > 3 originating from the surgical area. However, about 30% of patients still reported some pain-related functional impairment from the surgical area within four well-defined domains of everyday activities. Psychological and sensory thermal tests did not predict persistent postoperative pain, except preoperative pin-prick sensitivity was higher in patients with PPP. Postoperative pain 7 days after surgery was significantly higher in PPP patients. Preoperative pain originating from remote areas did not predict PPP.

CONCLUSION

The incidence of PPP, nerve damage (based on QST) and pain-related functional impairment following VATS was lower than reported following thoracotomy. No psychological or other factors predicted PPP. These findings call for further large-scale studies to support VATS to decrease PPP.

Management of unexpected intraoperative bleeding during thoracoscopic pulmonary resection: a single institutional experience

PURPOSE

Unexpected intraoperative bleeding during thoracoscopic surgery, necessitating emergency conversion to thoracotomy, is gradually being reported. We reviewed our experience of encountering unexpected bleeding during thoracoscopic surgery.

METHODS

We defined "unexpected intraoperative bleeding" as the need for hemostatic procedures with angiorrhaphy, with or without a sealant. The location, cause, and management of injured vessels, and perioperative outcomes were investigated and compared with those for patients without injured vessels.

RESULTS

Between 2007 and 2014, a total of 241 thoracoscopic anatomical pulmonary resections were performed at our hospital. Twenty (8.3 %) of these patients required hemostatic procedures with angiorrhaphy, with or without a sealant. The main injured vessels were the pulmonary artery (n = 13) and vein (n = 3) and the main causes of injury were related to technical issues with energy devices and staplers. There were no morbidities related to intraoperative bleeding. The operation time and blood loss were significantly greater in the patients with vessel injury than in those without vessel injury, but perioperative morbidities and the duration of chest tube insertion (4.5 vs. 3.5 days, average, p = 0.20) and postoperative hospital stay (12.7 vs. 11.0 days, average, p = 0.08) were not significantly different.

CONCLUSIONS

The frequency of unexpected bleeding was relatively high in this series, but its management and outcomes were satisfactory in terms of safety.

Postthoracotomy Pain Syndrome Following Surgery for Lung Cancer: Symptoms and Impact on Quality of Life

Postthoracotomy pain syndrome (PTPS) is a common complication following thoracic surgery. Most studies examining the influence of PTPS on patient-reported symptoms include few patients managed using a minimally invasive approach. Associated sensory changes, potentially neuropathic in origin, are not well described. We therefore examined the symptoms and quality of life (QOL) of patients with and without PTPS who underwent a standard thoracotomy (n = 43) or minimally invasive surgery (n = 54). Patients in this prospective, cross-sectional study completed questionnaires to assess pain (McGill Pain Questionnaire), neuropathic symptoms (Neuropathic Symptom Questionnaire), symptom distress (Symptom Distress Scale), anxiety and depression (Hospital Anxiety and Depression Scale), and QOL (Functional Assessment Cancer Therapy–Lung). Excepting younger age (p = .009), no demographic or surgical characteristic differentiated patients with and without PTPS. Patients with PTPS described discomfort as pain only (15.1%), neuropathic symptoms only (30.2%) or pain and neuropathic symptoms (54.7%). Scores differed between patients with and without PTPS for symptom distress (p < .001), anxiety and depression (p < .001), and QOL (p = .009), with higher distress associated with PTPS. Despite new surgical techniques, PTPS remains common and results in considerable distress. A focused assessment is needed to identify all experiencing this condition, with referral to pain management specialists if symptoms persist.

Inflammation-based scoring is a useful prognostic predictor of pulmonary resection for elderly patients with clinical stage I non-small-cell lung cancer

OBJECTIVES

The number of elderly lung cancer patients requiring surgery has been increasing due to the ageing society and less invasive perioperative procedures. Elderly people usually have various comorbidities, but there are few simple and objective tools that can be used to determine prognostic factors for elderly patients with clinical stage I non-small-cell lung cancer (NSCLC). The aim of this retrospective study was to evaluate the prognostic factors of surgically treated, over 80-year old patients with clinical stage I NSCLC.

METHODS

The preoperative data of 97 over 80-year old patients with clinical stage I NSCLC were collected at Nagasaki University Hospital from 1990 to 2012. As prognostic factors, inflammation-based scoring systems, including the Glasgow Prognostic Score (GPS) determined by serum levels of C-reactive protein and albumin, the neutrophil lymphocyte ratio (NLR) and the platelet lymphocyte ratio (PLR) were evaluated, as well as other clinicopathological factors, including performance status, body mass index, carcinoembryonic antigen, Charlson comorbidity index and type of surgical procedure.

RESULTS

The median age was 82 (range, 80-93) years. There were 62 (64.0%) clinical stage IA cases and 35 IB cases. Operations included 64 (66.0%) lobectomies, 15 segmentectomies and 18 wedge resections. The pathological stage was I in 76 (78.4%) patients, II in 12 (12.4%), III in 8 (8.2%) and IV in 1 (1.0%). Twelve (12.4%) patients underwent mediastinal lymph node dissection. Overall survival and disease-specific 5-year survival rates were 55.5 and 70.0%, respectively. The average GPS score was 0.4 (0-2). Disease-specific 5-year survival was significantly longer with GPS 0 than with GPS 1-2. (74.2%, 53.7%, respectively, P = 0.03). Overall 5-year survival was significantly longer with GPS 0 than with GPS 1-2. (59.7%, 43.1%, respectively, P = 0.005). Both the NLR (median value = 1.9) and the PLR (median value = 117) were not correlated with disease-specific and overall 5-year survival. On multivariate analysis, pathological stage I (P = 0.01) and GPS 0 (P = 0.04, hazard ratio: 2.13, 95% confidence interval 1.036-4.393) were significant prognostic factors.

CONCLUSIONS

The preoperative GPS appears to be a useful predictor of overall survival and could be a simple prognostic tool for elderly patients with clinical stage I NSCLC.

Incidence and severity of chronic pain at 3 and 6 months after thoracotomy: meta-analysis

This systematic review was performed to determine the incidence and the severity of chronic pain at 3 and 6 months after thoracotomy based on meta-analyses. We conducted MEDLINE, Web of Science, and Google Scholar searches of databases and references for English articles; 858 articles were reviewed. Meta-regression analysis based on the publication year was used to examine if the chronic pain rates changed over time. Event rates and confidence intervals with random effect models and Freeman-Tukey double arcsine variance-stabilizing transformation were obtained separately for the incidence of chronic pain based on 1,439 patients from 17 studies at 3 months and 1,354 patients from 15 studies at 6 months. The incidences of chronic pain at 3 and 6 months after thoracotomy were 57% (95% confidence interval [CI], 51-64%) and 47% (95% CI, 39-56%), respectively. The average severity of pain ratings on a 0 to 100 scale at these times were 30 ± 2 (95% CI, 26-35) and 32 ± 7 (95% CI, 17-46), respectively. Reported chronic pain rates have been largely stable at both 3 and 6 months from the 1990s to the present.

PERSPECTIVE

This systematic review's findings suggest that reported chronic pain rates are approximately 50% at 3 and 6 months and have been largely stable from the 1990s to the present. The severity of this pain is not consistently reported. Chronic pain after thoracotomy continues to be a significant problem despite advancing perioperative care.

The Qualitative Hyperalgesia Profile: A New Metric to Assess Chronic Post-Thoracotomy Pain

Thoracotomy often results in chronic pain, characterized by resting pain and elevated mechano-sensitivity. This paper defines complex behavioral responses to tactile stimulation in rats after thoracotomy, shown to be reversibly relieved by systemic morphine, in order to develop a novel qualitative "pain" score. A deep incision and 1 hour of rib retraction in male Sprague-Dawley rats resulted in reduced threshold and a change in the locus of greatest tactile (von Frey filament) sensitivity, from the lower back to a more rostral location around the wound site, and extending bilaterally. The fraction of rats showing nocifensive responses to mild stimulation (10 gm) increased after thoracotomy (from a pre-operative value of 0/10 to 8/10 at 10 days post-op), and the average threshold decreased correspondingly, from 15 gm to ∼4 gm. The nature of the nocifensive responses to tactile stimulation, composed pre-operatively only of no response (Grade 0) or brief contractions of the local subcutaneous muscles (Grade I), changed markedly after thoracotomy, with the appearance of new behaviors including a brisk lateral "escape" movement and/or a 180° rotation of the trunk (both included as Grade II), and whole body shuddering, and scratching and squealing (Grade III). Systemic morphine (2.5 mg/kg, i.p.) transiently raised the threshold for response and reduced the frequency of Grade II and III responses, supporting the interpretation that these represent pain. The findings support the development of a Qualitative Hyperalgesic Profile to assess the complex behavior that indicates a central integration of hyperalgesia.

Chest tube insertion is one important factor leading to intercostal nerve impairment in thoracic surgery

OBJECTIVES

Chest tube insertion seems to be one important factor leading to intercostal nerve impairment. The purpose of this prospective study was to objectively evaluate intercostal nerve damage using current perception threshold testing in association with chest tube insertion.

METHODS

Sixteen patients were enrolled in this study. Intercostal nerve function was assessed with a series of 2000-Hz (Aβ fiber), 250-Hz (Aδ fiber), and 5-Hz (C fiber) stimuli using current perception threshold testing (Neurometer CPT/C(®)). Current perception threshold values at chest tube insertion were measured before surgery, during chest tube insertion and after removal of the chest tube. Intensities of ongoing pain were also assessed using a numeric rating scale (0-10).

RESULTS

Current perception thresholds at each frequency after surgery were significantly higher than before surgery. Numeric rating scale scores for pain were significantly reduced from 3.3 to 1.9 after removal of the chest tube (p = 0.004). The correlation between current perception threshold value at 2000 Hz and intensity of ongoing pain was marginally significant (p = 0.058).

CONCLUSIONS

This is the first study to objectively evaluate intercostal nerve damage at chest tube insertion. The results confirmed that chest tube insertion has clearly deleterious effects on intercostal nerve function.

Late sensory changes following chest drain insertion during thoracotomy

BACKGROUND

It is well known that chest drains are associated with severe movement-related acute pain. These noxious stimuli could play a significant role in development and maintenance of persistent post-operative pain. Therefore we studied chest drain sites in post-thoracotomy pain syndrome (PTPS) patients, in regard to pain and sensory dysfunction.

METHODS

We quantified thermal and pressure thresholds on both the chest drain side and the contralateral side in 11 PTPS patients and 10 pain-free post-thoracotomy patients 33 months after the thoracotomy. On average, each patient had two chest drains inserted during surgery.

RESULTS

At follow up, two patients experienced pain at the chest drain sites, but had maximal pain near or at the thoracotomy scar. Comparison between chest drain side and control side for all 21 patients demonstrated significantly elevated thresholds for warmth detection and heat pain on the chest drain side (P < 0.01), but not for cool detection or pressure. No significant differences between chest drain side and control side were observed within PTPS or pain-free patients. Comparing PTPS and pain-free patients (chest drain-to-control side), no significant differences in thresholds were found. Although all 11 PTPS patients suffered from incisional pain, only two patients had pain from chest drains.

CONCLUSION

Increased thresholds for thermal detection suggest that chest drain insertion is associated with late nerve injury. Because no significant differences in sensory thresholds between PTPS and pain-free patients were found, the pathophysiological role of small fibre nerve injury from chest drains in relation to PTPS remains unclear.

[Progress of post-thoracotomy pain-relief strategies]

本文对开胸术后疼痛的预防和治疗策略作一简明综述，并主要关注外科手术操作技术的改进对于减轻开胸术后疼痛的作用，同时也兼顾了一些麻醉药物方面的进展。尽管已有诸多相关研究在手术方式和药物镇痛两个方面对治疗和预防开胸术后疼痛进行了一些探索，但由于疼痛的个体差异、手术者操作技术的差别以及研究样本量的限制，目前尚难得出确切的结论支持其中的某种方法为“最优”选择。这一领域仍期待着临床专家的深入探索和研究。

Abdominal wall bulging after thoracic surgery, an underdiagnosed wound complication

BACKGROUND

Complications after thoracic surgery have well been established, pain being the most prominent. Intercostal nerves are mixed type nerves combining motor and sensory functions. This notion is not consistent with the incidence of PTPS compared to the incidence of muscle paresis or paralysis. We would hypothesize that abdominal wall paresis or paralysis is underdiagnosed.

METHODS

In our hospital, three patients developed abdominal wall paralysis after thoracic surgery and consequent nerve damage. Their cases are discussed, and a review of the literature was conducted concerning (intercostal) nerve damage on a cellular level, the anatomy of the intercostal nerve, prevention of intercostal nerve damage and surgical techniques.

RESULTS

A cellular cascade known as Wallerian degeneration and regeneration determine whether a damaged nerve can function again. The recovery of the nerve is highly dependent on the correct function of activated Schwann cells and macrophages and is related to the amount of damage that has taken place. The anatomy of the intercostal nerve makes it susceptible to injury. Retractor placement during open thoracic surgery has shown to effect compression injury and induced mechanical deformation and damage. Given the known factors of pathophysiology and anatomy, a number of preventive measures have been tested to reduce intercostal nerve damage. Several techniques have been proposed, but the most used technique, the video-assisted thoracic surgery, has been the most effective in reducing nerve damage.

CONCLUSION

Abdominal wall paralysis is an underdiagnosed complication after thoracic surgery. The amount of stress on the intercostal nerves could be reduced with less invasive techniques such as the VATS technique.