Shoulder function after thoracic surgery

The Incidence of Winged Scapula after Thoracic Cancer Surgery: A Prospective Cohort Study

BACKGROUND

 Lung cancer is the leading cause of cancer-related deaths, and surgery is still the first treatment of choice in early and locally advanced cases. One of the iatrogenic complications is the serratus anterior palsy, which could lead to a winged scapula (WS). Unfortunately, the incidence of this deficit in thoracic surgery is unclear. Our primary aim was to determine the incidence of WS in lung cancer patients in a single-center experience.

METHODS

 We conducted a retrospective analysis of prospectively collected data with patients eligible for oncological thoracic surgery from March 2013 until January 2014. A physical evaluation of the WS was performed pre- and postoperatively, at the discharge and after 1 year of follow-up.

RESULTS

 A total of 485 patients were evaluated; 135 (27.8%) showed WS. Longer operative time (p < 0.0001), type of surgery (p < 0.0001), lymphadenectomy (p < 0.0001), and neoadjuvant treatment prior surgery (p = 0.0005) were significantly related to the WS injury. Multivariable analysis showed that type of surgery was significantly associated with WS (p < 0.0001). After 1 year, 41.6% still had WS.

CONCLUSION

 The incidence of WS was similar to the literature. As WS incidence is underdiagnosed, assessment and correct education about possible deficits or impairments should be improved. Moreover, when a minimally invasive approach is not planned, it is a good clinical practice to discuss surgical strategies with surgeons to reduce this deficit.

Trap-Door Thoracotomy and Clamshell Thoracotomy as Surgical Approaches for Neuroblastoma and Other Thoracic Tumors in Children

Solid tumors of the cervicothoracic junction, the posterior mediastinum, or bilateral dorsal thoracic tumors represent a challenge in pediatric surgical oncology. The aim of this study was to evaluate trap-door thoracotomy and clamshell thoracotomy as surgical approaches. A single-center retrospective study of children with solid tumors in these specific localizations was performed. From 2015 to 2023, 26 children (17 girls; 9 boys) were treated at a median age of 54 months (range 8-229). Tumor resection was performed for neuroblastoma (n = 11); metastatic disease (n = 7); malignant rhabdoid tumor (n = 4); Ewing sarcoma (n = 1); inflammatory myofibroblastic tumor (n = 1); rhabdomyosarcoma (n = 1); and neurofibroma (n = 1). The surgical goal of macroscopic complete excision was achieved in all of the 14 children who underwent trap-door thoracotomy and in 11 of the 12 children who underwent clamshell thoracotomy. There were no major complications. At a median follow-up of 8 months (range 0-60), the disease was under local control or in complete remission in 66.7% of the children. In conclusion, surgical resection of solid tumors of the cervicothoracic junction in children can be performed safely and successfully with trap-door thoracotomy and with clamshell thoracotomy for posterior mediastinal or bilateral dorsal thoracic tumors.

Efficacy of Phrenic Nerve Block and Suprascapular Nerve Block in Amelioration of Ipsilateral Shoulder Pain after Thoracic Surgery: A Systematic Review and Network Meta-Analysis

Background and Objectives: Ipsilateral shoulder pain (ISP) is a common complication after thoracic surgery. Severe ISP can cause ineffective breathing and impair shoulder mobilization. Both phrenic nerve block (PNB) and suprascapular nerve block (SNB) are anesthetic interventions; however, it remains unclear which intervention is most effective. The purpose of this study was to compare the efficacy and safety of PNB and SNB for the prevention and reduction of the severity of ISP following thoracotomy or video-assisted thoracoscopic surgery. Materials and methods: Studies published in PubMed, Embase, Scopus, Web of Science, Ovid Medline, Google Scholar and the Cochrane Library without language restriction were reviewed from the publication's inception through 30 September 2022. Randomized controlled trials evaluating the comparative efficacy of PNB and SNB on ISP management were selected. A network meta-analysis was applied to estimate pooled risk ratios (RRs) and weighted mean difference (WMD) with 95% confidence intervals (CIs). Results: Of 381 records screened, eight studies were eligible. PNB was shown to significantly lower the risk of ISP during the 24 h period after surgery compared to placebo (RR 0.44, 95% CI 0.34 to 0.58) and SNB (RR 0.43, 95% CI 0.29 to 0.64). PNB significantly reduced the severity of ISP during the 24 h period after thoracic surgery (WMD -1.75, 95% CI -3.47 to -0.04), but these effects of PNB were not statistically significantly different from SNB. When compared to placebo, SNB did not significantly reduce the incidence or severity of ISP during the 24 h period after surgery. Conclusion: This study suggests that PNB ranks first for prevention and reduction of ISP severity during the first 24 h after thoracic surgery. SNB was considered the worst intervention for ISP management. No evidence indicated that PNB was associated with a significant impairment of postoperative ventilatory status.

Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial

Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP. Our primary aim was to assess the effect of PNB on postoperative ISP, following video-assisted thoracic surgery (VATS).

Post-thoracotomy ipsilateral shoulder pain: What should be preferred to optimize it - phrenic nerve infiltration or paracetamol infusion?

Background

Post thoracotomy ipsilateral shoulder pain (PTISP) is a distressing and highly prevalent problem after thoracic surgery and has not received much attention despite the incidence as high as 85%.

Objectives

To study the effect of phrenic nerve infiltration with Ropivacaine compared to paracetamol infusion on PTISP in thoracotomy patients with epidural analgesia as standard mode of incisional analgesia in both the groups.

Study Design

Prospective Randomised and Double Blind Study.

Methods

126 adult patients were divided randomly into 2 groups, "Group A (Phrenic Nerve Infiltration Group) received 10 mL of 0.2% Ropivacaine close to the diaphragm into the periphrenic fat pad" and "Group B (Paracetamol Infusion Group) received 20mg/kg paracetamol infusion" 30 minutes prior to chest closure respectively. A blinded observer assessed the patients PTISP using the VAS score at 1, 4, 8, 12 and 24 hours (h) postoperatively. The time and number of any rescue analgesic medication were recorded.

Results

PTISP was relieved significantly in Group A (25.4℅) as compared to Group B (61.9℅), with significantly higher mean duration of analgesia in Group A. The mean time for first rescue analgesia was significantly higher in Group A (11.1 ± 7.47 hours) than in Group B (7.40 ± 5.30 hours). The number of rescue analgesic required was less in Group A 1.6 ± 1.16 as compared to Group B 2.9 ± 1.37 (P value <0.5).

Conclusions

Phrenic Nerve Infiltration significantly reduced the incidence and delayed the onset of PTISP as compared to paracetamol infusion and was not associated with any adverse effects.

Musculoskeletal Signs Associated with Shoulder Pain in Patients Undergoing Video-Assisted Thoracoscopic Surgery

BACKGROUND

Lung cancer is the leading cause of cancer death worldwide, and lung resection still represents the main curative treatment modality. Although video-assisted thoracoscopic surgery has emerged as a minimally invasive alternative, its relationship with shoulder musculoskeletal signs remains unclear.

OBJECTIVE

To characterize shoulder dysfunction in patients after video-assisted thoracoscopic surgery and to analyze its influence on quality of life.

DESIGN AND SETTING

A longitudinal observational prospective cohort study has been carried out in the Thoracic Surgery Service of the Hospital Virgen de las Nieves (Granada).

SUBJECTS

Fifty-nine patients undergoing video-assisted thoracoscopic surgery were included.

METHODS

Patients were assessed before surgery, at discharge, and one month after discharge. Musculoskeletal disturbances, pain severity, and health status were assessed. Musculoskeletal outcomes measured were range of movement and trigger points, both bilaterally. Additionally, pain severity and health status were measured with Brief Pain Inventory and Euroqol-5 dimensions.

RESULTS

Significant differences were found at discharge in trigger points of ipsilateral and contralateral upper limbs. One month after surgery, no muscle returned to baseline measures, and ipsilateral and contralateral shoulders presented a decreased range of motion, as well as poor quality of life and high severity and interference of pain.

CONCLUSIONS

Video-assissted thoracoscopic surgery was associated with musculoskeletal shoulder dysfunction, which remained one month after the intervention. This musculoskeletal dysfunction included significant dysfunction in both shoulders with a decreased range of movement, an increase in trigger points, poor quality of life, and high severity and interference of pain.

Characteristic Movement of the Ribs, Thoracic Vertebrae while Elevating the Upper Limbs - Influences of Age and Gender on Movements

Background:

The rib cage, such as the thoracic spine and ribs, influences glenohumeral mobility and the development of shoulder disorders.

Objective:

To evaluate movements of the ribs, thoracic vertebrae during bilateral arm elevation and to clarify the characteristic influences of age and gender.

Methods:

Subjects comprised 33 healthy individuals divided into a young group (10 males, 7 females; mean age, 25 years) and a middle-aged group (8 males, 8 females; mean age, 52 years). Chest CT was performed with two arm positions: arms hanging downwards; and arms elevated at 160°. Images were three-dimensionally reconstructed to evaluate rib movement, extension angle of thoracic vertebrae.

Results:

Maximal movement was observed at the fifth rib, and rib movement decreased with increasing distance from the fifth rib in both the groups. In males, movement of the second to fourth ribs was smaller in the middle-aged group than in the young group (p < 0.05). Movement of the first to ninth ribs was smaller in females than in males (p < 0.05). No significant difference in the extension angle of the thoracic vertebrae was found.

Conclusion:

Fifth rib movement is the largest among all ribs during bilateral arm elevation. Reduction of upper rib movement initially arises as an age-related degradation in males. Women exhibit less rib movement during bilateral arm elevation.

Essentials of Physiotherapy after Thoracic Surgery: What Physiotherapists Need to Know. A Narrative Review

Physiotherapy has recently become an essential part of enhanced recovery protocols after thoracic surgery. The evidence-based practice of physiotherapy is essential for the effective management of postoperative patients. Unfortunately, only a small body of literature has discussed the rationale of the physiotherapy interventions that are routinely implemented following thoracic surgery. Nonetheless, we can integrate the available knowledge into our practice until new evidence emerges. Therefore, in this review, the principles of physiotherapy after thoracic surgery are presented, along with a detailed description of physiotherapy interventions, with the goals of enhancing the knowledge and practical skills of physiotherapists in postoperative care units and helping them to re-evaluate and justify their traditional practices.

Postthoracotomy Ipsilateral Shoulder Pain: A Literature Review on Characteristics and Treatment

Context. Postthoracotomy Ipsilateral Shoulder Pain (IPS) is a common and sometimes intractable pain syndrome. IPS is different from chest wall pain in type, origin, and treatments. Various treatments are suggested or applied for it but none of them is regarded as popular accepted effective one. Objectives. To review data and collect all present experiences about postthoracotomy IPS and its management and suggest future research directions. Methods. Search in PubMed database and additional search for specific topics and review them to retrieve relevant articles as data source in a narrative review article. Results. Even in the presence of effective epidural analgesia, ISP is a common cause of severe postthoracotomy pain. The phrenic nerve has an important role in the physiopathology of postthoracotomy ISP. Different treatments have been applied or suggested. Controlling the afferent nociceptive signals conveyed by the phrenic nerve at various levels—from peripheral branches on the diaphragm to its entrance in the cervical spine—could be of therapeutic value. Despite potential concerns about safety, intrapleural or phrenic nerve blocks are tolerated well, at least in a selected group of patient. Conclusion. Further researches could be directed on selective sensory block and motor function preservation of the phrenic nerve. However, the safety and efficacy of temporary loss of phrenic nerve function and intrapleural local anesthetics should be assessed.

Transcutaneous Electrical Nerve Stimulation Reduces Post-Thoractomy Ipsilateral Shoulder Pain. A Prospective Randomized Study

OBJECTIVES

The patient's position during an axillary thoracotomy can cause postoperative pain and decrease mobility of the ipsilateral shoulder. In this study, we assessed whether the implementation of a standardized analgesia program using transcutaneous electrical nerve stimulation (TENS) decreases local pain and improves ipsilateral shoulder mobility.

METHOD

Randomized, single-blind, single-center clinical trial of 50 patients who had undergone anatomical lung resection via axillary muscle-sparing thoracotomy. Patients were treated with TENS devices for 30 minutes every 8 hours, beginning on postoperative day 1. Pain and mobility of the affected limb were recorded at the same time on postoperative days 1 through 3. A visual analogue scale was used for pain assessment and shoulder mobility was assessed with a goniometer. Results were compared using a non-parametric test.

RESULTS

Twenty-five patients were randomized to each group. Mean age of the control group was 62.7±9.3 years and 63.4±10.2 years in the experimental group. Shoulder mobility parameters were similar in both groups on all postoperative days. However, pain during flexion significantly decreased on day 2 (P=.03) and day 3 (P=.04) in the experimental group.

CONCLUSION

The use of TENS decreases pain from shoulder flexion in patients undergoing axillary thoracotomy for pulmonary resection.

Lung cancer screening and video-assisted thoracic surgery

INTRODUCTION

The objective of this study is to report the impact of computed tomography (CT) screening on the use of Video-Assisted Thoracic Surgery (VATS) in a randomized screening trial.

METHODS

The Danish Lung Cancer Screening Trial is a randomized clinically controlled trial of 4104 smokers and previous smokers who were randomized to either screening with five annual low-dose CT scans or no screening in Copenhagen from 2004 to 2006. The major end point is the effect of CT screening on lung cancer mortality and treatment options. All diagnostic and treatment interventions in both groups were monitored prospectively until 1 to 3 years after the last screening round.

RESULTS

By February 1, 2011 68 cases of lung cancer were detected in the screening group. Furthermore, seven patients with a benign nodule underwent surgical treatment because of suspicion of malignancy (12%). Fifty-one of the 68 lung cancer patients were eligible for surgical treatment. Eight patients had open thoracotomy. Of the operations for lung cancer, 84% were performed by VATS in the CT-screened arm, significantly higher than the control arm (p < 0.05). Thirty-six patients had a VATS lobectomy. One patient had a VATS segmentectomy, and four patients had a VATS wedge resection. The seven benign nodules were all treated with VATS.

CONCLUSIONS

CT screening seems to facilitate the use of VATS in the treatment of lung cancer with an 84% rate in our data. Furthermore, all benign nodules could be removed by VATS. In our view, a basic requirement for a surgical institution to be involved in lung cancer CT screening is a dedicated VATS program.

Spondylectomy of T-2 according to the Tomita technique via an extended Fessler approach: a cadaveric study

Object

The authors' aim was to conduct a surgical anatomy and feasibility study on the use of an extended posterolateral approach to the cervicothoracic junction (Fessler approach) in cadavers to facilitate en bloc removal of the second thoracic vertebra using the Tomita technique. To apply this technique, it is mandatory to approach both sides of the vertebra. But such a maneuver is very difficult in the region of the cervicothoracic junction because the scapula and its muscles represent an anatomical barrier to the paravertebral compartment and lateral aspects of the vertebrae.

Methods

To study the extended posterolateral Fessler approach to the cervicothoracic junction and the possible application of the Tomita technique on the second thoracic vertebra, 3 fresh-frozen cadavers were used in the Laboratory of Human Anatomy at the University of Nantes.

Results

The proposed approach allows exposure of both the posterior arch and the body of the second thoracic vertebra without any significant resection or traction of the superficial and deep posterior thoracic muscles, enabling application of the Tomita technique and facilitating intraoperative spinal fixation.

Conclusions

The proposed surgical technique is technically feasible. Nevertheless, it should be an option reserved for selected patients for whom the surgical complexity can be justified by the characteristics of their malignancy and expected curative outcome.

Video-assisted thoracic surgery for superior posterior mediastinal neurogenic tumour in the supine position

Video-assisted thoracic surgery (VATS) for a superior posterior mediastinal lesion is routinely done in the lateral decubitus position similar to a standard thoracotomy using a double-lumen endotracheal tube for one-lung ventilation. This is an area above the level of the pericardium, with the superior thoracic opening as its superior limit and its inferior limit at the plane from the sternal angle to the level of intervertebral disc of thoracic 4 to 5 vertebra lying behind the great vessels. The lateral decubitus position has disadvantages of the double-lumen endotracheal tube getting malpositioned during repositioning from supine position to the lateral decubitus position, shoulder injuries due to the prolonged abnormal fixed posture and rarer injuries of the lower limb. There is no literature related to VATS in the supine position for treating lesions in the posterior mediastinum because the lung tissue falls in the dependent posterior mediastinum and obscures the field of surgery; however, VATS in the supine position is routinely done for lesions in the anterior mediastinum and single-stage bilateral spontaneous pneumothorax. Thus, in the selected cases, ‘VATS in supine position’ allows an invasive procedure to be completed in the most stable anatomical posture.

A postoperative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial

QUESTION

Does a postoperative physiotherapy exercise program incorporating shoulder exercises improve shoulder function, pain, range of motion, muscle strength, and health-related quality of life in patients undergoing elective pulmonary resection via open thoracotomy?

DESIGN

Randomised trial with concealed allocation, assessor blinding, and intention-to-treat analysis.

PARTICIPANTS

76 patients who underwent pulmonary resection via open thoracotomy.

INTERVENTION

All participants received standard medical and nursing care involving a clinical pathway. The experimental group also received physiotherapy interventions that included daily supervised, progressive exercises until discharge and a postoperative exercise booklet on discharge.

OUTCOME MEASURES

Preoperatively and up to 3 months postoperatively pain was measured with a numerical rating scale, shoulder function with the Shoulder Pain and Disability Index, and quality of life with the Short Form-36. Shoulder range of motion and muscle strength were measured in a subgroup.

RESULTS

The experimental group had 1.3 units (95% CI 0.3 to 2.2) less shoulder pain (scored /10) and 2.2 units (95% CI 0.2 to 4.3) less total pain (scored /30) at discharge, and 7.6% (95% CI 1.7 to 13.6) better function at 3 months. The Short Form-36 physical component score was 4.8 points (95% CI -0.3 to 10.0) better for the experimental group than the control group at 3 months. Differences between groups in all range of motion and strength measures were small and statistically non-significant.

CONCLUSION

A physiotherapist-directed postoperative exercise program resulted in significant benefits in pain and shoulder function over usual care for patients following open thoracotomy.

TRIAL REGISTRATION

ANZCTRN 12605000201673.

Technical advances in mediastinal surgery: videothoracoscopic approach to posterior mediastinal tumors

Videothoracoscopic approach to posterior mediastinal tumors is a safe operation in experienced hands. This approach produces results comparable to the other conventional surgical techniques for excision. This article describes the operative procedure and summarizes the advantages of this approach.

Recent advances in video-assisted thoracoscopic approach to posterior mediastinal tumours

Minimal invasive video-assisted thoracic surgery can be a safe alternative technique in the assessment, diagnosis and surgical resection of posterior mediastinal tumours. Video-assisted thoracic surgery may be particularly suited for the management of posterior mediastinal tumours as most are benign. Surgical technique continues to evolve from the classic 3-port access in order to tackle more complex tumours positioned at the apical and inferior recesses of the posterior mediastinum. The preoperative identification of dumbbell tumours is important to facilitate arrangements for a single-stage combined resection for both the intra-thoracic and intraspinal tumour. Results from Video-assisted thoracic surgery posterior mediastinal tumour resection are comparable with conventional surgical techniques in terms of symptomatic improvement, recurrence and survival. Video-assisted thoracic surgery approach has been shown to result in less post-operative pain, improved cosmesis, shorter hospital stay, and more rapid recovery and return to normal activities. In over a decade, video-assisted thoracic surgery has gradually matured and is now a promising therapeutic alternative to open approach. In certain selected patients, video-assisted thoracic surgery may be considered the standard of care for conditions of the posterior mediastinum. Recent developments in robotic surgery for the management of mediastinal tumours are promising, however, long-term results are pending.

Thoracoscopy versus thoracotomy improves midterm musculoskeletal status and cosmesis in infants and children

BACKGROUND

It has been postulated that video-assisted thoracoscopic surgery (VATS) achieves a better biometric and aesthetic outcome than conventional thoracic surgery (CTS), but data are lacking. We aimed to compare the midterm effects of both approaches in children.

METHODS

Sixty-two infants and children, who underwent VATS (34; 55%) or CTS (28; 45%) for benign thoracic conditions, were evaluated at follow-up after a mean of 3.8 years (1 to 7 years). The patients underwent standardized clinical assessment of the skeletal system and function. The intercostal spaces were investigated for rib fusion by ultrasound. Patients (+/- parents) themselves, as well as clinicians, subsequently assessed the scars.

RESULTS

Comparing the operated versus nonoperated sides, chest asymmetry was significantly less frequent after VATS versus CTS in the horizontal plane (mean relative difference 0.996 +/- 0.003 vs 0.964 +/- 0.008, p < 0.001) and in nipple location (mean relative difference 0.985 +/- 0.008 vs 0.949 +/- 0.013, p = 0.047). The ranges of motion of the shoulder joints did not differ significantly. However, the incidence of scoliosis was lower in VATS patients (9% vs 54%, p < 0.001) and the intercostal spaces of the operated hemithoraces were narrower after CTS (p < 0.001). The Manchester scar assessment scores were in favor of VATS (mean 7.5 vs 13.1, p < 0.001). The visual analog scale scores recorded by patients-parents and independent observers were also significantly better after VATS. Patient satisfaction was less with CTS as 10% wanted to have the scar revised, compared with none in the VATS group.

CONCLUSIONS

The thoracoscopic versus conventional approach to the thoracic cavity in children is associated with significantly less midterm musculoskeletal sequelae and a better cosmetic outcome.

Does physiotherapy reduce the incidence of postoperative complications in patients following pulmonary resection via thoracotomy? a protocol for a randomised controlled trial

BACKGROUND

Postoperative pulmonary and shoulder complications are important causes of postoperative morbidity following thoracotomy. While physiotherapy aims to prevent or minimise these complications, currently there are no randomised controlled trials to support or refute effectiveness of physiotherapy in this setting.

METHODS/DESIGN

This single blind randomised controlled trial aims to recruit 184 patients following lung resection via open thoracotomy. All subjects will receive a preoperative physiotherapy information booklet and following surgery will be randomly allocated to a Treatment Group receiving postoperative physiotherapy or a Control Group receiving standard care nursing and medical interventions but no physiotherapy. The Treatment Group will receive a standardised daily physiotherapy programme to prevent respiratory and musculoskeletal complications. On discharge Treatment Group subjects will receive an exercise programme and exercise diary to complete. The primary outcome measure is the incidence of postoperative pulmonary complications, which will be determined on a daily basis whilst the patient is in hospital by a blinded assessor. Secondary outcome measures are the length of postoperative hospital stay, severity of pain, shoulder function as measured by the self-reported shoulder pain and disability index, and quality of life measured by the Medical Outcomes Study Short Form 36 v2 New Zealand standard version. Pain, shoulder function and quality of life will be measured at baseline, on discharge from hospital, one month and three months postoperatively. Additionally a subgroup of subjects will have measurement of shoulder range of movement and muscle strength by a blinded assessor.

DISCUSSION

Results from this study will contribute to the increasing volume of evidence regarding the effectiveness of physiotherapy following major surgery and will guide physiotherapists in their interventions for patients following thoracotomy.

TRIAL REGISTRATION

The study protocol is registered with the Australian and New Zealand Clinical Trials registry (ANZCTRN12605000201673).

Video-assisted thoracic surgery major lung resection can be safely taught to trainees

BACKGROUND

Video-assisted thoracoscopic surgery (VATS) major lung resection for lung cancer has been an important part of thoracic surgical training program in our institution. In this study, we compared the results of VATS major lung resection performed by surgical trainees with those performed by experienced thoracic surgeons with specialist interest in VATS.

METHODS

From January 2002 to October 2006, the clinical data of 111 consecutive patients scheduled for VATS major lung resection were prospectively entered into the computerized clinical management system of the local health authority; these include patient demographics, comorbidity, operating time, postoperative complications, and outcome. We retrospectively compared the data of patients who were operated on by trainees with those who were operated on by experienced VATS surgeons.

RESULTS

One hundred and eleven patients with clinical stage I and II lung cancer underwent VATS major lung resection. Fifty-one (46%) of the procedures were performed by consultant surgeons and 60 VATS lung resections (54%) were performed by supervised trainees. Patients' demography and risk factors were comparable between the two groups. Trainees spent more time in performing the operation as compared with experienced VATS surgeons (mean operating time 162 minutes, p = 0.01). There was no significant difference in intraoperative or postoperative complications and outcomes between the two groups.

CONCLUSIONS

Video-assisted thoracic surgery major lung resection for early stage nonsmall-cell lung cancer can be taught to residents who work under the supervision of experienced VATS surgeons. Video-assisted thoracic surgery major lung resection for lung cancer should be an integral part of thoracic surgical training program.

Low-Volume Interscalene Brachial Plexus Block for Post-Thoracotomy Shoulder Pain

OBJECTIVES

This study was designed to evaluate the effectiveness of low-volume interscalene brachial plexus block for post-thoracotomy ipsilateral shoulder pain and to compare it with nonsteroidal anti-inflammatory drug treatment.

DESIGN

Prospective nonblinded study.

SETTING

University hospital.

PARTICIPANTS

Sixty adult patients.

INTERVENTION

Patients who underwent elective thoracic surgery under combined epidural and general anesthesia, and after surgery were free of incisional pain but complaining of shoulder pain, were included in the study. They were selected in a sequential manner and placed into 2 groups of 30 patients each. Group 1 had a low-volume interscalene brachial plexus block, using 10 mL of bupivacaine 0.5%. Group 2 had an intramuscular injection of diclofenac sodium, 75 mg.

MEASUREMENTS AND MAIN RESULTS

Pain was measured during their stay in the postanesthesia care unit (PACU) by using a visual analog score (VAS). Opioids were administered when pain relief was incomplete. Pain intensity was re-estimated the next morning and patient satisfaction was scored. VAS was found to be significantly lower in the low-volume interscalene block group than in the diclofenac group at 30 minutes after treatment and when leaving PACU (p < 0.001 for both). Patients in the interscalene block group stayed longer in the PACU (p = 0.019), and significantly fewer required rescue opioids (p = 0.03). There was no significant difference between the groups in patient satisfaction with the pain treatment.

CONCLUSIONS

The authors concluded that low-volume interscalene brachial plexus block is a superior treatment for post-thoracotomy shoulder pain compared with diclofenac injection, although it requires a slightly longer stay in the PACU.

The physiotherapy management of patients undergoing thoracic surgery: a survey of current practice in Australia and New Zealand

BACKGROUND AND PURPOSE

Physiotherapy is considered an essential component of the management of patients after thoracotomy, yet the type of interventions utilized, and evidence for their efficacy, has not been established. The aim of the present study was to ascertain the current physiotherapy management of patients undergoing thoracotomy and the factors influencing practice among different providers.

METHOD

A purpose-designed postal questionnaire was distributed to senior physiotherapists in all thoracic surgical units throughout Australia and New Zealand (n=57).

RESULTS

A response rate of 81% was obtained (n=46). Pre-operatively, 16 respondents (35%) reported assessing all thoracotomy patients. The majority of respondents (n=44; 96%) indicated that all patients were seen by physiotherapists after surgery, with 29 respondents (63%) performing prophylactic physiotherapy interventions to prevent post-operative pulmonary complications. Respondents reported that physiotherapy treatment was usually commenced on day one post-operatively (n=37; 80%) with the most commonly used treatment interventions being deep breathing exercises, the active cycle of breathing techniques, cough, forced expiration techniques and sustained maximal inspirations. Most respondents reported that patients first sat out of bed (n=41; 89%), commenced shoulder range of movement (n=23; 50%) and walking (n=32; 70%) on day one post-operatively. The majority of respondents reported that they offered no post-operative pulmonary rehabilitation (n=25; 54%), outpatient follow-up (n=43; 94%) orpost-thoracotomy pain management (n=40; 87%). Respondents indicated that personal experience, literature recommendations and established practice were the factors which most influenced physiotherapy practice. Conclusion. Most patients after thoracotomy receive physiotherapy assessment and/or treatment in the immediate post-operative period, but only one-third were routinely seen pre-operatively and relatively few were reviewed following discharge from hospital. Further studies are required to guide physiotherapists in determining the efficacy of their practices for patients undergoing thoracotomy.

The dual etiology of ipsilateral shoulder pain after thoracic surgery⋆

Ipsilateral shoulder pain after thoracic surgery is a distressing problem and is associated with impairment of respiratory and shoulder function. The most suggested etiology for this shoulder pain is referred phrenic nerve pain. However, we have made clinical observations that suggest shoulder ligament strain as another cause of the shoulder pain.

Management of postthoracotomy pain: acute and chronic

Given the discomfort of thoracic surgical incisions, thoracic surgeons must understand and use contemporary multimodality pain treatments. Acute postthoracotomy pain not only causes psychologic distress to the patient but also has detrimental effects on pulmonary function and postoperative mobility, leading to increased morbidity. By choosing the most appropriate and least traumatic surgical incision, adhering to meticulous surgical techniques, and avoiding intercostal nerve injury or rib fractures, surgeons can minimize postoperative pain. Aggressive perioperative and postoperative pain management is best accomplished with use of an epidural anesthetic and covering breakthrough pain with an IV-PCA. Alternatively, an infusion system for continuous administration of local anesthetics directly in the subpleural plane, posterior to the intercostal incision, also provides excellent pain control. Again, use of an IV-PCA as adjuvant therapy is recommended. With careful planning, severe pain and its negative impact on thoracic surgical patients can be prevented.