Non-serratus-sparing antero-axillary thoracotomy with disconnection of anterior rib cartilage. Improvement in postoperative pulmonary function and pain in comparison to posterolateral thoracotomy

Chronic Postsurgical Pain Following Lung Transplantation: Characteristics, Risk Factors, Treatment, and Prevention: A Narrative Review

Chronic pain after lung transplantation (LTx) can substantially reduce quality of life (QoL), yet current consensus guidelines say little about how to prevent or manage it. Research on pain after LTx has tended to focus on acute rather than chronic pain, and it has not extensively examined the factors associated with onset or resolution of chronic pain, which differ from factors influencing chronic pain after general thoracic surgery. This narrative review explores what is known about the epidemiology and risk factors of chronic pain after LTx, as well as effective ways to treat or prevent it. The review identifies key questions and issues that should be the focus of future research.

Prognostic factors for chronic post-surgical pain after lung and pleural surgery: a systematic review with meta-analysis, meta-regression and trial sequential analysis

Chronic post-surgical pain is known to be a common complication of thoracic surgery and has been associated with a lower quality of life, increased healthcare utilisation, substantial direct and indirect costs, and increased long-term use of opioids. This systematic review with meta-analysis aimed to identify and summarise the evidence of all prognostic factors for chronic post-surgical pain after lung and pleural surgery. Electronic databases were searched for retrospective and prospective observational studies as well as randomised controlled trials that included patients undergoing lung or pleural surgery and reported on prognostic factors for chronic post-surgical pain. We included 56 studies resulting in 45 identified prognostic factors, of which 16 were pooled with a meta-analysis. Prognostic factors that increased chronic post-surgical pain risk were as follows: higher postoperative pain intensity (day 1, 0-10 score), mean difference (95%CI) 1.29 (0.62-1.95), p < 0.001; pre-operative pain, odds ratio (95%CI) 2.86 (1.94-4.21), p < 0.001; and longer surgery duration (in minutes), mean difference (95%CI) 12.07 (4.99-19.16), p < 0.001. Prognostic factors that decreased chronic post-surgical pain risk were as follows: intercostal nerve block, odds ratio (95%CI) 0.76 (0.61-0.95) p = 0.018 and video-assisted thoracic surgery, 0.54 (0.43-0.66) p < 0.001. Trial sequential analysis was used to adjust for type 1 and type 2 errors of statistical analysis and confirmed adequate power for these prognostic factors. In contrast to other studies, we found that age had no significant effect on chronic post-surgical pain and there was not enough evidence to conclude on sex. Meta-regression did not reveal significant effects of any of the study covariates on the prognostic factors with a significant effect on chronic post-surgical pain. Expressed as grading of recommendations, assessment, development and evaluations criteria, the certainty of evidence was high for pre-operative pain and video-assisted thoracic surgery, moderate for intercostal nerve block and surgery duration and low for postoperative pain intensity. We thus identified actionable factors which can be addressed to attempt to reduce the risk of chronic post-surgical pain after lung surgery.

Post-Thoracotomy Pain: Current Strategies for Prevention and Treatment

Treating acute pain after thoracotomy surgery and preventing the development of chronic post-thoracotomy pain syndrome (PTPS) remain significant challenges in this surgical population. While appropriately treated acute thoracotomy pain often resolves, a significant number of patients develop PTPS, with up to 65% of patients experiencing some pain and 10% suffering life-altering, debilitating pain. Currently, there is very little known about specific molecular targets or novel therapeutic combinations that effectively prevent PTPS. Identifying modifiable clinical risk factors (procedure, physical and mental health, preoperative pain in the surgical area and another regions) seems to the most pragmatic approach for prevention for now. Effective acute pain management adopting a multimodal approach can result in a decreased incidence of PTPS. Interventional techniques such as paraverterbral blocks, intercostal blocks, and erector spinae blocks show some promise as well. Future research should be focused on minimally invasive surgeries and also the effect of ERAS protocols, including early mobilization, nutrition, and early removal of drains, on the development of PTPS.

Early removal of chest tubes leads to better short-term outcome after video-assisted thoracoscopic surgery lung resection

Background

Currently, some studies have shown that early removal of a chest tube after video-assisted thoracoscopic surgery (VATS) lobectomy is safe and can shorten the length of hospital stay. The purpose of our study was to retrospectively analyze the association between early chest tube removal and hospital stay in patients who have undergone lobectomy.

Methods

This retrospective analysis included patients undergoing different types of lung resections including lobectomy and wedge resection. Consecutive patients who underwent VATS lobectomy or wedge resection (March 2018 to April 2019) for lung tumor were analyzed. Patients were divided into two groups according to the drainage time: those in whom the chest tube was removed within 48 hours and the traditional management group.

Results

All 931 patients were included. After propensity score matching (PSM). There are no statistically significant differences between the two groups. Compared with the traditional management group, the hospital stay in the early removal group was significantly shorter (5.05±2.27 vs. 7.17±3.03; P<0.001). Regarding complications, compared with the traditional management group, the rates of both lung infection and no complication in the early removal group were less (0.2% vs. 2.3%, 93.0% vs. 91.1%; P=0.005), and the necessity of re-operation was also less (0% vs. 1.2%; P<0.001). Regarding both pleural effusion and thoracentesis, a slight increase in the patient number was observed in the early removal group compared with the traditional management group (4.7% vs. 4.0%, 1.2% vs. 0.9%; P=0.005).

Conclusions

Compared with the traditional management group, early removal of the chest tube after VATS lobectomy and wedge resection is safe and feasible, and could decrease morbidity and postoperative complications, importantly, resulting in a shorter hospital stay.

Pain after posterolateral versus nerve-sparing thoracotomy: A randomized trial

OBJECTIVES

Post-thoracotomy pain leads to patient discomfort, pulmonary complications, and increased analgesic use. Intercostal nerve injury during thoracotomy or its entrapment during closure can contribute to post-thoracotomy pain. We hypothesized that a modified technique of posterolateral thoracotomy and closure, preserving the intercostal neurovascular bundle, would reduce acute and chronic post-thoracotomy pain.

METHODS

We randomized 90 patients undergoing posterolateral thoracotomy for pulmonary resection at a tertiary level oncology center to standard posterolateral (control arm) or modified nerve-sparing thoracotomy. All patients received morphine via patient-controlled analgesia pumps. The primary outcome was the worst postoperative pain score in the first 3 postoperative days. Secondary outcomes included the average pain score and analgesic requirements in the first 3 postoperative days and the incidence of post-thoracotomy pain 6 months after surgery.

RESULTS

No significant differences were seen between the groups in acute or chronic post-thoracotomy measured by the numeric rating scale. There was no difference seen in the worst (mean) postoperative pain scores (3.71 vs 3.83, difference 0.12; 99% confidence interval [CI], -0.7 to +0.9; P = .7), average (mean) pain scores in the first 3 postoperative days (1.77 vs 1.85, difference 0.08; 99% CI, -0.4 to +0.6; P = .69), mean consumption of morphine (mg/kg) (1.45 vs 1.40, difference -0.05; 99% CI, -0.4 to +0.3; P = .73), or incidence of chronic postoperative pain (37.8% vs 40%, difference 4.9%; 99% CI, -22.8 to +30.7%; P = .73).

CONCLUSIONS

The modified nerve-sparing thoracotomy technique does not reduce post-thoracotomy pain compared with standard posterolateral thoracotomy.

MUSCLE-SPARING VERSUS STANDARD POSTEROLATERAL THORACOTOMY IN NEONATES WITH ESOPHAGEAL ATRESIA

Background:

The muscle-sparing thoracotomy (MST) has not yet been thoroughly studied and assessed in comparison to the traditional thoracotomy method in newborns.

Aim:

To compare the outcomes of MST and standard posterolateral thoracotomy (PLT) in newborns.

Methods:

Randomized, controlled, double-blind trial on 40 neonates with esophageal atresia, comparing the time of beginning a surgery until seeing the pleura, the duration of hospitalization in the neonatal intensive care unit, the time in ventilator, the time of returning the shoulder function, the time of returning the Moro reflex, and the mortality between the two techniques.

Results:

The data showed no differences between the two groups in basic information (weight, height, gender, numbers of prematurity neonates and caesarean). The results on the size of the scar in the MST group was significantly lower than in the PLT group. Also, the time of returning the shoulder function in MST group was earlier than in PLT group. There were no significant differences in the duration since the beginning the surgery to see the pleura, the time of being hospitalized in intensive unit, the time that the infant required ventilator, returning time of the Moro reflex in 1^st and 3^rd months after the operation, and the mortality rates between MST and PLT groups.

Conclusion:

It seems that the advantages of using MST over PLT procedure in neonates include the earlier shoulder function recovery and also superior cosmetic results.

Chronification of Pain: Mechanisms, Current Understanding, and Clinical Implications

PURPOSE OF REVIEW

The development of acute to chronic pain involves distinct pathophysiological changes in the peripheral and central nervous systems. This article reviews the mechanisms, etiologies, and management of chronic pain syndromes with updates from recent findings in the literature.

RECENT FINDINGS

Chronic post-surgical pain (CPSP) is not limited to major surgeries and can develop after smaller procedures such as hernia repairs. While nerve injury has traditionally been thought to be the culprit for CPSP, it is evident that nerve-sparing surgical techniques are not completely preventative. Regional analgesia and agents such as ketamine, gabapentinoids, and COX-2 inhibitors have also been found to decrease the risks of developing chronic pain to varying degrees. Yet, given the correlation of central sensitization with the development of chronic pain, it is reasonable to utilize aggressive multimodal analgesia whenever possible. Development of chronic pain is typically a result of peripheral and central sensitization, with CPSP being one of the most common presentations. Using minimally invasive surgical techniques may reduce the risk of CPSP. Regional anesthetic techniques and preemptive analgesia should also be utilized when appropriate to reduce the intensity and duration of acute post-operative pain, which has been correlated with higher incidences of chronic pain.

Totally Endoscopic Cardiac Surgery for Atrial Septal Defect Repair on Beating Heart Without Robotic Assistance in 25 Patients

Supplemental digital content is available in the text.

Objective

The aim of the study was to investigate the effectivity and safety of totally endoscopic cardiac surgery without robotic assistance for atrial septal defect (ASD) closure on beating hearts.

Methods

Twenty-five patients (adults/children: 15/10) underwent ASD closure using nonrobotically assisted totally endoscopic approach on beating heart. Three 5-mm trocars and one 12-mm trocar were used, only the superior vena cava is snared, filling the pleural and pericardial cavities with CO₂, and the heart was beating during the surgery. Twenty-three patients had isolated secundum ASD (2 of which had severe tricuspid regurgitation) and two patients had ASD combined with partial anomalous pulmonary venous connection. All ASDs were closed using artificial patch, continuous suture; tricuspid regurgitations were repaired and the anomalous pulmonary veins were drained to the left atrium.

Results

No postoperative complications or deaths occurred. Mean ± SD operation time and mean cardiopulmonary bypass time were 267.2 ± 44.6 and 156.1 ± 33.6 min, respectively. These patients were extubated within the first 5 hours, and the volume of blood drainage on the first day was less than 80 mL. Four days after surgery, patients did not need analgesics and were able to return to normal activities 1 week postoperatively.

Conclusions

Totally endoscopic operation for ASD closure on beating heart is safe, with short recovery period, and surgical scars are of high cosmetic value, especially in a woman and girl.

Muscle sparing thoracotomy for esophageal cancer: a comparison with posterolateral thoracotomy

PURPOSE

The aim of this study was to investigate whether muscle sparing thoracotomy (MST) improved postoperative chest pain and an impairment of the postoperative pulmonary function in comparison with posterolateral thoracotomy (PLT).

METHODS

Twenty-four patients with esophageal cancer who underwent PLT from September 2006 to August 2008 and 30 patients who underwent MST from September 2008 to August 2010 were selected as subjects of this study. Postoperative acute and chronic chest pain and the recovery of the pulmonary function were retrospectively compared between the two groups.

RESULTS

The frequency of the additional use of analgesics was on days 3, 6, and 7 (mean 0.4 vs. 1.2, p = 0.027, 0.4 vs. 1.5, p = 0.007, and 0.2 vs. 1.2, p = 0.009, respectively) in the early postoperative period. The number of patients requiring analgesics at 1 and 3 months after surgery was significantly lower in the MST group than in the PLT group (13.3 vs. 58.3 %, p = 0.002, 10.0 vs. 50.0 %, p = 0.001, respectively). The postoperative vital capacity, expressed as a percentage of the preoperative value, 3 and 12 months after surgery was significantly higher in the MST group than in the PLT group (86.0 vs. 73.8 %, p = 0.028, 93.2 vs. 76.9 %, p = 0.002, respectively).

CONCLUSION

Compared with PLT, MST might, therefore, reduce postoperative chest pain and offer a better recovery of pulmonary function in patients with esophageal cancer.

Neuropathic aspects of persistent postsurgical pain: a French multicenter survey with a 6-month prospective follow-up

To investigate the role of peripheral neuropathy in the development of neuropathic postsurgical persistent pain (N-PSPP) after surgery, this French multicentric prospective cohort study recruited 3,112 patients prior to elective cesarean, inguinal herniorrhaphy (open mesh/laparoscopic), breast cancer surgery, cholecystectomy, saphenectomy, sternotomy, thoracotomy, or knee arthroscopy. Besides perioperative data collection, postoperative postal questionnaires built to assess the existence, intensity, and neuropathic features (with the Douleur Neuropathique 4 Questions [DN4]) of pain at the site of surgery were sent at the third and sixth months after surgery. In the 2,397 patients who completed follow-up, the cumulative risk of N-PSPP within the 6 months ranged from 3.2% (laparoscopic herniorrhaphy) to 37.1% (breast cancer surgery). Pain intensity was greater if DN4 was positive and decreased with time since surgery; it depended on the type of surgery. In pain-reporting patients, the response to the DN4 changed from time to time in about 1:4 of the cases. Older age and a low anxiety score were independent protective factors of N-PSPP, whereas a recent negative event, a low preoperative quality of life, and previous history of peripheral neuropathy were risk factors. The type of anesthesia had no influence on the occurrence of N-PSPP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00812734.

PERSPECTIVE

This prospective observational study provides the incidence rate of N-PSPP occurring within the 6 months after 9 types of elective surgical procedures. It highlights the possible consequences of nerve aggression during some common surgeries. Finally, some preoperative predispositions to the development of N-PSPP have been identified.

When does acute pain become chronic?

The transition from acute to chronic pain appears to occur in discrete pathophysiological and histopathological steps. Stimuli initiating a nociceptive response vary, but receptors and endogenous defence mechanisms in the periphery interact in a similar manner regardless of the insult. Chemical, mechanical, and thermal receptors, along with leucocytes and macrophages, determine the intensity, location, and duration of noxious events. Noxious stimuli are transduced to the dorsal horn of the spinal cord, where amino acid and peptide transmitters activate second-order neurones. Spinal neurones then transmit signals to the brain. The resultant actions by the individual involve sensory-discriminative, motivational-affective, and modulatory processes in an attempt to limit or stop the painful process. Under normal conditions, noxious stimuli diminish as healing progresses and pain sensation lessens until minimal or no pain is detected. Persistent, intense pain, however, activates secondary mechanisms both at the periphery and within the central nervous system that cause allodynia, hyperalgesia, and hyperpathia that can diminish normal functioning. These changes begin in the periphery with upregulation of cyclo-oxygenase-2 and interleukin-1β-sensitizing first-order neurones, which eventually sensitize second-order spinal neurones by activating N-methyl-d-aspartic acid channels and signalling microglia to alter neuronal cytoarchitecture. Throughout these processes, prostaglandins, endocannabinoids, ion-specific channels, and scavenger cells all play a key role in the transformation of acute to chronic pain. A better understanding of the interplay among these substances will assist in the development of agents designed to ameliorate or reverse chronic pain.

High Incidence of Chronic Pain Following Surgery for Pelvic Fracture

OBJECTIVES

To determine the incidence of chronic pain after surgery for pelvic fracture using a strict definition and measures of intensity and health-related quality of life.

METHODS

In April 2004, a questionnaire was sent to 221 patients who underwent surgery for pelvic fracture in the period 1996 to 2000. Chronic pain was defined as pain at present that related back to the pelvic fracture and was not a consequence of other disease. Health-related quality of life was measured using the 15D questionnaire.

RESULTS

The response rate was 72.9% after a median follow-up of 5.6 years. Chronic pain was seen in 48.4% (95% confidence interval, 40.7%-56.2%). These patients had a combination of somatic nociceptive, visceral nociceptive, and neuropathic pain and had significantly lower health-related quality of life. Also, the use of opioids (14.1% vs. 4.8%) and nonsteroidal anti-inflammatories/paracetamol (57.7% vs. 21.7%), the request for financial compensation (75.6% vs. 45.8%), and complications related to leg function (62.8% vs. 20.5%) were significantly higher in the group with chronic pain than in the group without chronic pain.

CONCLUSIONS

Chronic pain after pelvic fracture is a major problem that affects a patient's quality of life. The use of analgesics was higher in these patients, and they had more complications. Chronic pain after surgery for pelvic fracture deserves more attention.

Antero-lateral thoracotomy

Lateral thoracotomies include many different variants with a common final pathway, consisting of an intercostal incision. They are the most frequent incisions in daily thoracic procedures. We will describe the antero-lateral thoracotomy. Although these incisions are seldom used, it should be part of the surgeon's 'general culture'. Surgical techniques, indications, pitfalls and tips are described. Discussion and an overview of the literature are developed.

Muscle-splitting posterolateral thoracotomy: a novel technique

PURPOSE

In an effort to decrease the morbidity of a standard posterolateral thoracotomy, numerous muscle-sparing approaches have been developed. However, these incisions have been limited by the need for excessive muscle retraction with resultant neuropraxia, difficulty with exposure, and postoperative wound seroma. We report our results of a novel muscle-splitting thoracotomy incision, which affords excellent exposure without significant morbidity.

METHODS

We conducted a retrospective chart review of 37 consecutive patients who underwent "muscle-splitting" thoracotomy from June 1997 to June 1998. The technique, which involves a bidirectional spread of the latissimus dorsi and serratus anterior muscles, was performed by the same attending surgeon in all patients.

RESULTS

There were 22 male and 15 female patients, aged 26 to 81 (mean, 58), with a body mass index ranging from 18 to 40 kg/m(2) (mean, 25 kg/m(2)). Procedures included lobectomy/segmentectomy (19), wedge resection (5), pneumonectomy (2), Belsey IV fundoplication (5), Ivor-Lewis esophagogastrectomy (1), T8/T9 thoracic exposure (1), and miscellaneous thoracic cases (4). Operative time ranged from 90 minutes to 420 minutes (mean, 176), which was comparable with similar procedures through a standard incision. No patients required conversion to a muscle-cutting thoracotomy.

CONCLUSIONS

Our technique of muscle-splitting posterolateral thoracotomy appears to provide excellent operative exposure and to avoid problems seen with current muscle-sparing incisions. A prospective, randomized trial to compare this technique with a standard thoracotomy incision would be useful in determining its viability as an alternative thoracic approach.

Consequences of Inadequate Postoperative Pain Relief and Chronic Persistent Postoperative Pain

Inadequately controlled pain has undesirable physiologic and psychologic consequences such as increased postoperative morbidity, delayed recovery, a delayed return to normal daily living, and reduced patient satisfaction. Importantly, the lack of adequate postoperative pain treatment may lead to persistent pain after surgery, which is often overlooked. Overall, inadequate pain management increases the use of health care resources and health care costs. This article reviews the physiologic and psychologic consequences of inadequately treated pain, with an emphasis on chronic persistent postoperative pain.

Six-minute walking and pulmonary function test outcomes during the early period after lung cancer surgery with special reference to patients with chronic obstructive pulmonary disease

OBJECTIVE

To evaluate physical dysfunction during the early period after lung resection in patients with lung cancer and coexisting chronic obstructive pulmonary disease (COPD), we examined the relationship between the ratio of the forced expiratory volume in 1 second to the forced vital capacity (FEV1/FVC%) and the results of a 6-minute walk (6MW) test before and after surgery.

METHODS

Eighty-three patients who underwent lobectomy for lung cancer were classified into three groups according to their preoperative FEV1/FVC: more than 70% (non-COPD, n = 61), 60-69% (mild COPD, n = 15), and 40-59% (moderate COPD, n = 7). The 6MW and pulmonary function tests were performed before surgery and repeated 1 and 2 weeks after surgery. During the 6MW test, the distance covered during a 6MW test (6MWD) and the decrease in oxygen saturation (SpO2) were measured.

RESULTS

During both the preoperative and postoperative 6MW tests, the decrease in SpO2 correlated significantly with the preoperative FEV1/FVC% (p < 0.001). The percentage decrease in 6MWD at 1 and 2 weeks after surgery correlated significantly with the preoperative FEV1/FVC% (p < 0.001 and p = 0.04, respectively), but not with the concomitant percentage reduction in vital capacity (VC). The differences of the decreases in postoperative 6MWD and SpO2 during the 6MW test were significant between the moderate and mild COPD patients and between the mild COPD and non-COPD patients (p < 0.01-0.001).

CONCLUSION

The decreases in 6MWD and SpO2 after surgery were significantly influenced by the preoperative FEV1/FVC%, but not by the decrease in VC. COPD patients have a limited capacity for walking during the early period after surgery due to significant oxygen desaturation.

Acute and chronic pain syndromes after thoracic surgery

Pain is one of the most important considerations in the care of thoracic surgical patients. Failure in pain management is associated with increased mortality and morbidity. Acute pain management aspires to stop the painful stimuli before it is transferred to the CNS. The authors recommend (1) a thorough explanation of the operation and the expected outcome to the patient, (2) preoperative pulmonary rehabilitation for those with marginal lung function, (3) choosing the least painful surgical approach with acceptable exposure, (4) minimizing tissue trauma during surgery, (5) preemptive analgesia, and (6) early ambulation as prophylactic measures that should be employed during hospitalization. Good acute pain control should reduce the incidence of chronic pain. Mediansternotomy and VATS seem to be less acutely painful approaches than thoracotomy for most thoracic surgery. One should rule out recurrent malignancy as the etiology for chronic or recurrent pain. Opioids and NSAIDs are sufficient to produce optimal pain control in patients who undergo VATS and sternotomv. TEA is typically reserved for patients who have a thoracotomy. Opioid PCA can be used instead of-or after the discontinuation of-the epidural catheter. Chronic pain can be treated in many ways, and input from a pain clinic might be beneficial. The single best approach to chronic pain is to prevent it. This can be achieved by selecting the right incisional approach, instituting early physical therapy, and achieving optimal postoperative pain control.

What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery?

BACKGROUND

To clarify any advantages of video-assisted thoracoscopic surgery (VATS) over anterior limited thoracotomy (ALT) for lobectomy in lung cancer, we compared the two procedures in a retrospective analysis.

METHODS

Sex- and age-matched (+/- 5 years) lung cancer patients in clinical stage I who underwent lobectomy by means of VATS (n = 33) or ALT (n = 33) were compared in terms of the number of resected lymph nodes, operating time, intraoperative blood loss, duration of postoperative chest tube drainage, and chest pain. Pain was evaluated using a visual analog scale and analgesic requirements. Vital capacity (VC), respiratory muscle strength, and results of a 6-minute walking (6 MW) test were also compared preoperatively and 1 and 2 weeks postoperatively.

RESULTS

Compared with the ALT group, the VATS group experienced less pain between postoperative day (POD) 1 and POD 7 (p < 0.05 to 0.001) and had lower analgesic requirements up to POD 7 (p < 0.001). However, there were no significant differences in pain on POD 14. There were also no significant differences in intraoperative factors or in the postoperative impairment of VC, respiratory muscle strength, and 6 MW test results.

CONCLUSIONS

Although VATS lobectomy reduces chest pain during the first week after surgery compared with ALT, this advantage is lost within 2 weeks. Both techniques result in similar impairments of pulmonary function, respiratory muscle strength and walking capacity. Therefore, if curative resection of lung cancer by VATS would be technically difficult for any reason, including the surgeon's skill and experience, a limited open thoracotomy would be preferable from the standpoints of safety and the patient's prognosis.

Intrathoracic light-assisted anterior limited thoracotomy in lung cancer surgery

We recently developed an intrathoracic light-assisted anterior limited thoracotomy (ILAALT) for use in lung cancer surgery. A skin incision 12cm long is made below the breast, then the pectoral major muscle is divided, and the fourth intercostal space is opened with a disconnection of the anterior cartilagenous portion. The posterior skin, including the serratus anterior muscle, is drawn posteriorly using a retractor. To illuminate the posterior and apex portions of the thoracic cavity, a flexible fiber light is introduced into the thoracic cavity through the eighth intercostal space at the posterior axillary line. These techniques provided adequate exposure and sufficient illumination in the thoracic cavity, thus making surgery easy for most thoracic applications. Using this approach, we undertook 28 lung resections with a mediastinal nodal dissection for lung cancer (24 lobectomies, 2 bilobectomies, and 2 pneumonectomies) without difficulty. The mean intrasurgical blood loss was 217ml, the operative time 262min, and chest tube drainage duration 2.3 days. Except for one case, no patients required a blood transfusion. All patients underwent continuous epidural anesthesia until postoperative day (POD) 8. The mean time that other analgesic medication was required was 0.5 times per patient until POD 13, but none from POD 14 on. We thus conclude ILAALT to be low-invasive thoracotomy and is thus indicated for most types of lung cancer surgery, providing a reduction of pain as its main advantage.

Anterior limited thoracotomy with intrathoracic illumination for lung cancer: its advantages over anteroaxillary and posterolateral thoracotomy

STUDY OBJECTIVE

We developed anterior limited thoracotomy (ALT) with intrathoracic illumination for curative resection of lung cancer. The present study evaluated the benefits of ALT by retrospective comparison with anteroaxillary thoracotomy (AAT) and posterolateral thoracotomy (PLT).

DESIGN

Lung cancer patients, who underwent lobectomy via ALT (n = 28), AAT (n = 28), and PLT (n = 28), were matched by gender and age. Operating time, blood loss during operation, chest tube drainage volume 24 h after surgery, chest tube drainage duration, and vital capacity (VC) and chest pain from early to late postoperative period were studied for ALT, AAT, and PLT. Early postoperative chest pain was evaluated by a visual analog scale and analgesic requirements, and chronic pain was divided into five grades.

RESULTS

No difference was observed in operating time among ALT, AAT, and PLT. ALT has the following advantages over PLT: (1) less blood loss during surgery (p < 0.05); (2) reduced postoperative drainage volume (p < 0.05) resulting in shorter chest tube drainage (p < 0.001); (3) diminished impairment of VC for 1 week to 6 months after surgery (p < 0.01 or p < 0.001); and (4) reduced pain from 1 day and 6 months after surgery (p < 0.001). ALT also has the advantage over AAT in reduced pain 5 days (p < 0.01) and 7 days (p < 0.05) after surgery and in decreased analgesic requirements during 14 days after surgery (p < 0.05).

CONCLUSION

ALT is a sufficient and minimally invasive thoracotomy alternative to PLT or AAT for curative lung cancer resection.

Post-thoracotomy pain control

Publications on post-thoracotomy pain control obtained by Medline search were reviewed from June 1997 to July 1998. The main focus points in the past year were the effect of new surgical techniques on analgesia after thoracic surgery and the use of extrapleural catheters in the paravertebral space as a method of continuous intercostal nerve block. Epidural and patient-controlled analgesia techniques are still widely used and are mostly effective, but some patients may still have unacceptable levels of pain in the first 24 hours.

Muscle-sparing anterior thoracotomy for one-stage bilateral lung volume reduction operation

Bilateral lung volume reduction produces significant clinical and physiologic improvement in selected patients with end-stage emphysema. Current surgical approaches consist of median sternotomy and video-assisted thoracoscopy. This report describes an alternate technique of single-stage, bilateral lung volume reduction using muscle-sparing anterior thoracotomy in 18 patients with severe lung emphysema.