Surgical aspects of chronic post-thoracotomy pain

The morbidity of open transthoracic approach for anterior scoliosis correction

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the patient satisfaction and the patients' perceived approach-related morbidity (ArM) after open thoracotomy (OTC) for instrumented anterior scoliosis surgery.

SUMMARY OF BACKGROUND DATA

There is no mid- to long-term data on the patients' perceived ArM concerning chest wall dissection for open anterior scoliosis correction.

METHODS

A specific questionnaire was used to retrospectively evaluate mid- to long-term follow-up data concerning ArM after OTC of patients younger than 30 years (range, 11-28 years) who underwent anterior open transthoracic scoliosis surgery. The questionnaire was comprised of detailed scar-related questions. Applying strict inclusion criteria, we could analyze outcomes in terms of percentage morbidity (morbidity [%]) of 40 patients who underwent OTC for instrumented scoliosis correction.

RESULTS

Mean age of the patients was 16 ± 3.8 years, follow-up was 61.5 ± 72.6 months on average, and mean incision length was 25.7 ± 3.1 cm. Mean number of levels fused was 5.9 ± 1.5. Single thoracotomy was performed in 25 patients and a thoracoabdominal approach in 15 patients. Mean morbidity (0%, not delineating no ArM; 100%, delineating highest ArM) was 5.4% ± 11.3%; 47.5% of patients had no morbidity; 12.5% had morbidity >10% (mean: 28.5%). Signs of intercostal neuralgia (ICN) were present in 10%. Patients judged their clinical outcome as "good" in 20% and "excellent" in 80%. Statistical analysis did not reveal differences in outcomes and percentage morbidity concerning age of patients, extent of approach (thoracotomy vs. thoracoabdominal approach) and incision length, gender, or follow-up length. However, the presence of ICN had a significant effect on the outcome, showing high correlation with increased morbidity (P < 0.0001). In the clinical judgment of outcomes, the severity of the ArM after OTC was mild, except for 2 patients who had moderate approach and scar-related morbidity.

CONCLUSION

ArM after open thoracic spinal surgery or thoracoscopic procedures can be assessed using the questionnaire. The current study showed that ArM in young patients who underwent OTC for anterior instrumented scoliosis correction was low. Patients with increased signs of ICN did worse in terms of the questionnaire survey. The study showed that neither cosmesis nor scar-related problems were a concern for patients undergoing OTC.

Subcutaneous targeted neuromodulation technique for the treatment of intractable chronic postthoracotomy pain

Subcutaneous targeted neuromodulation has been used successfully in chronic neuropathic pain. A 26 year-old patient with severe postthoracotomy pain and ipsilateral "wing scapula" due to intraoperative injury of the long thoracic nerve, is reported. Application of targeted neuromodulation resulted in immediate pain relief and marked improvement of shoulder function at one-year follow-up. The technique may be an effective alternative treatment of chronic and intractable postoperative painful conditions.

[Surgical treatment of diaphragmatic eventrations and paralyses]

Surgical treatment of eventration or paralysis of the diaphragm is symptomatic and non curative, and depends on whether the dysfunction is of peripheral or central origin. Elevation of a hemidiaphragm of peripheral origin, the most frequent situation, needs surgical treatment only in case of major functional effects (effort or positional dyspnoea, cardiac or digestive symptoms, or pain) that persists despite optimal conservative management. Selection of candidates for surgery depends on a thorough morphological and functional investigation of the neuromuscular and respiratory components. Surgical plication of the diaphragm through a lateral thoracotomy or by video-thoracoscopy is a recognized, safe and effective procedure. Its low morbidity and mortality, which are mainly associated with co-morbid factors, and its long-lasting functional benefit of around 100%, show that it is an effective procedure. In the case of bilateral dysfunction, occasional cases of bilateral plication have been reported. Some cases of diaphragmatic paralysis of central causation result in a life of ventilator dependence, even though the peripheral neuromuscular and respiratory systems are intact. In selected cases, following a complete functional investigation, phrenic nerve pacing may be attempted to achieve ventilator weaning. To date, there are two validated indications for this technique: Tetraplegia above C3 and alveolar hypoventilation of central cause. After thoracic implantation, a progressive reconditioning of the diaphragmatic muscle allows weaning from the ventilator in a few weeks in more than 90% of patients. Their quality of life is greatly improved thanks to independence from the ventilator, more physiological respiration, restoration of smell and better speech. Whether the diaphragmatic dysfunction is peripheral or central in origin, the success of surgical treatment depends on rigorous preoperative selection of patients.

Approach-related morbidity in transthoracic anterior spine surgery: a clinical study and review of literature

BACKGROUND: Anterior access to the thoracic spine is done by open thoracotomy (OTC) or video-assisted thoracoscopic surgery (VATS). VATS is known as the method which results in lower morbidity rates, but there is little evidence of its less invasiveness. Objective: The current study yielded for outcome data concerning patients' perception of approach-related morbidity (ArM) following OTC for spinal surgery and that of a control group having a chest tube thoracotomy (CTT). METHODS: We performed a questionnaire assessment of ArM after OTC and CTT. Applying strict inclusion criteria, we compared outcomes in terms of percentage morbidity (Morbidity %) of 43 patients that underwent OTC for instrumented scoliosis correction to 30 patients that had CTT for minor thoracic pathologies (e.g., pneumothorax). RESULTS: Mean age in CTT and OTC Group was 50.2 and 16.5 years old, follow-up was of 32.2 and 58.4 months, and mean incision length was 2.5 and 25.5 cm, respectively. Mean number of levels fused in the OTC Group was 5.8. Mean morbidity (0% delineating no cases, 100% delineating highest morbidity) for the CTT Group was 10.8±15.4% (0-59.5%), 42% of patients had no morbidity. Signs of intercostal neuralgia (ICN) were present in 16.7%. A total of 35.5% had a morbidity >10% (mean: 27.5%), and 10% of morbidity cases were defined as having a chronic post-thoracotomy pain (CPP). In the OTC Group, mean morbidity was 7.0±12.7% (0-52.1%), 44% had no morbidity. Out of the sample, 18.6% had morbidity >10% (mean: 28.6%). Signs of ICN were present in 14%. In both groups, the presence of ICN had a significant impact on and showed correlation with morbidity (p<0.0001). In terms of clinical judgement, the severity of the ArM after a CTT or OTC was generally mild except for one patient in each group. Age and follow-up were significantly different between groups (p<0.0001, p=0.02), but the intergroup difference in morbidity was not significant (p=0.08). CONCLUSIONS: ArM after open thoracic spinal surgery or VATS procedures can be assessed using the questionnaire. To put ArM of OTC into perspective, a Control Group with simple CTT was selected, demonstrating that morbidity was not different between the OTC and CTT groups. Patients with increased signs of ICN do worse which was reflected by increased morbidity in both groups. The study demonstrates that not only the cosmesis is not a concern for patients undergoing OTC, but neither is the ArM a concern, equalling that of a simple CTT.

Rib fracture repair: indications, technical issues, and future directions

Rib fracture repair has been performed at selected centers around the world for more than 50 years; however, the operative indications have not been established and are considered controversial. The outcome of a strictly nonoperative approach may not be optimal. Potential indications for rib fracture repair include flail chest, painful, movable rib fractures refractory to conventional pain management, chest wall deformity/defect, rib fracture nonunion, and during thoracotomy for other traumatic indication. Rib fracture repair is technically challenging secondary to the human rib's relatively thin cortex and its tendency to fracture obliquely. Nonetheless, several effective repair systems have been developed. Future directions for progress on this important surgical problem include the development of minimally invasive techniques and the conduct of multicenter, randomized trials.

Natural Orifice Translumenal Thoracoscopic Surgery

Context. Natural orifice translumenal endoscopic surgery (NOTES) is an emerging new technique but with much of the focus for the clinical applications of this technique centered on the abdomen. Concequently, its adaptation to the chest has been overlooked. The evidence for safe access, periprocedural complications and potential thoracic applications needs to be evaluated. Objective. This study systematically reviews the evidence for the feasibility and potential clinical applications of natural orifice translumenal thoracoscopic surgery. Data sources. MEDLINE and the Cochrane central database of controlled trials, from the earliest available date to July 2008. Study selection and data extraction. All studies evaluating the use of NOTES involving the thoracic cavity or structures therein were identified. The minimum inclusion criterion for each study was the extraction of discernible trial data. No restrictions were placed on language. Results. The literature search identified 197 citations. Review of abstracts led to 10 full-text articles for assessment; 7 articles were considered for this review, reporting on a total of 37 cases. All cases used the porcine model in both survival (7 to 42 days; mean 16; n = 5) and nonsurvival studies (n = 2). Mortality was 5% (n = 2) and morbidity 19% (n = 7); histopathological leak was detected on autopsy in 1 case. Conclusion. No human trials have currently been performed using NOTES within the thoracic cavity. There is a wide diversity of clinical applications from which cardiothoracic surgery could potentially benefit. There is a great deal of technical improvement that is still required before the technique is viable as an alternative surgical approach in humans.

Management of chronic pain in cancer survivors

Chronic pain is a frequent complication of cancer and its treatments and is often underreported, underdiagnosed, and undertreated. Pain in cancer survivors is caused by residual tissue damage from the cancer and/or the cancer therapy. This pain can be divided into 3 pathophysiologic categories: somatic, visceral, and neuropathic. The most common treatment-induced chronic pain syndromes are neuropathies secondary to surgery, radiation therapy, and chemotherapy. Comfort and function are optimized in cancer survivors by a multidisciplinary approach using an individually tailored combination of opioids, coanalgesics, physical therapy, interventional procedures, psychosocial interventions, and complementary and alternative modalities. Management of chronic pain must be integrated into comprehensive cancer care so that cancer patients can fully enjoy their survival.

Symptom Severity 1 to 4 Months After Thoracotomy for Lung Cancer

Background Information about the severity of symptoms during recovery from surgery for lung cancer can be useful in planning and anticipating needs for recovery.

Objectives To describe symptom severity during the first 4 months after thoracotomy for non–small cell lung cancer and factors associated with overall symptom severity at 1 and 4 months.

Methods Ninety-four patients were assessed at 1, 2, and 4 months after thoracotomy by using the Lung Cancer Symptom Scale, Brief Pain Inventory, Schwartz Fatigue Scale, Dyspnea Index, and Center for Epidemiology Studies–Depression Scale (CES-D). Clinically meaningful changes, decrease in the proportion of patients with severe symptoms, and relationships among symptoms were determined. Mixed effects models for repeated measures were used to evaluate changes in severity. Multiple regression models were used to examine correlates of overall symptoms.

Results Mean symptom severity significantly decreased over time for most symptoms. Only disrupted appetite, pain, and dyspnea had clinically meaningful improvement at 4 months. Severe symptoms included fatigue (57%), dyspnea (49%), cough (29%), and pain (20%). Prevalence of depressed mood decreased at 4 months. Most patients (77%) had comorbid conditions. Number of comorbid conditions and CES-D explained 54% of the variance in symptom severity at 1 month; comorbid conditions, male sex, neoadjuvant treatment, and CES-D score explained 50% of the variance at 4 months.

Conclusions Severe symptoms continued 4 months after surgery for some patients, indicating the need for support during recovery, especially for patients with multiple comorbid conditions and depressed mood.

Postthoracotomy paravertebral analgesia: will it replace epidural analgesia?

Thoracotomy is associated with significant acute postoperative pain and a high incidence of development of chronic pain. Thoracic epidural analgesia has long been standard treatment for postthoracotomy pain, but recently there has been increased interest in alternative regional techniques, particularly paravertebral analgesia. This article compares the analgesic efficacy, side effects, complications of, and contraindications for thoracic epidural and paravertebral analgesia techniques and discusses their effects on the development of chronic postthoracotomy pain. This information will allow a more considered choice of analgesic technique after thoracotomy.

Genetic and environmental determinants of postthoracotomy pain syndrome

PURPOSE OF REVIEW

Pain after thoracic surgery may persist for up to a year or longer in as many as 50% of patients undergoing lung resection. There is currently no specific therapy, and our ability to predict who will develop a persistent pain syndrome is poor at best. Persistent pain after thoracotomy is not an acute somatic pain, rather it is a complex syndrome with many of the characteristics of neuropathic, dysesthetic pain.

RECENT FINDINGS

The pain genetics field has been dominated by reports of single variants leading to severe phenotypes. These (Mendelian) diseases are not representative of the more common, complex phenotype that is characterized by the lay term 'pain threshold'. Recently, work describing the association of genetic variants with idiopathic pain disorders has appeared in the literature, and here the authors suggest that these concepts are applicable to postthoracotomy pain syndrome.

SUMMARY

Postthoracotomy pain syndrome likely arises as a direct result of an environmental stress (surgery) occurring on a landscape of susceptibility that is determined by an individual's behavioral, clinical and genetic characteristics.

Video assisted thoracic surgery in children

Thoracoscopic surgery, i.e., video assisted thoracic surgery (VATS) has been in use in children for last 98 years. Its use initially was restricted to the diagnostic purposes. However, with the improvement in the optics, better understanding of the physiology with CO2 insufflation, better capabilities in achieving the single lung ventilation and newer vessel sealing devices have rapidly expanded the spectrum of the indication of VATS. At present many complex lung resections, excision of mediastinal tumors are performed by VATS in the experienced centre. The VATS has become the standard of care in empyema, lung biopsy, Mediastinal Lymphnode biopsy, repair of diaphragmatic hernia, etc. The article discusses the indications of VATS, techniques to achieve the selective ventilation and surgical steps in the different surgical conditions in children.

Sequels 10 years after thoracoscopic procedures for benign disease

OBJECTIVE

Video-assisted thoracic surgery (VATS) is recognized to be as effective as open thoracic surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity. Chronic postoperative pain (CPP) is defined as persisting more than 2 months after the procedure. CPP and other neurological sensations like dysesthesia or numbness are found frequently, but little is known about the outcome of those patients many years after the primary procedure.

METHODS

In 1999 we retrospectively investigated a group of 46 (31.9%) out of 144 patients who were identified with sequels at a mean of 32 months after a VATS procedure. Now at 123 months postoperation we reinvestigated those patients for ongoing sequels.

RESULTS

Out of 46 patients, 36 were still alive and could be reached for an interview. Eighteen patients (50%) were now free from symptoms while 18 patients (50%) still suffered from sequels. From the group of 144 patients operated on, sequels were now present in 18 patients (12.5% at 123 months vs 31.4% at 32 months, p=0.0002). Pain was present in 17 patients (11.8% vs 20.1%, p=0.11), in 3 patients (2.1% vs 18.1%, p<0.000001) even at rest, and in 4 patients (2.7% vs 12.5%, p=0.0002) only at exercise. Ten patients (6.9% vs 28.5%, p=0.096) suffered from pain occasionally, e.g. because of changing weather. Painkillers were taken only by one patient (0.7% vs 16.6%, p<0.0001) occasionally, and the sequels impacted the life of one female patient (0.7% vs 13.2%, p<0.0001) badly. Numbness was present in 16.9% versus 1.3% (p=0.0013) of patients.

CONCLUSION

Early postoperative sequels are frequently found in VATS procedures, but patients with pain even after years have a nearly 50% chance to eliminate their problems. In addition, numbness and dysesthesia seem to disappear almost completely several years after the procedure.

Diaphragm plication in adult patients with diaphragm paralysis leads to long-term improvement of pulmonary function and level of dyspnea

OBJECTIVE

There is still controversy about the feasibility and long-term outcome of surgical treatment of acquired diaphragm paralysis. We analyzed the long-term effects on pulmonary function and level of dyspnea after unilateral or bilateral diaphragm plication.

METHODS

Between December 1996 and January 2006, 22 consecutive patients underwent diaphragm plication. Before surgery, spirometry in both seated and supine positions and a Baseline Dyspnea Index were assessed. The uncut diaphragm was plicated as tight as possible through a limited lateral thoracotomy. Patients with a follow-up exceeding 1 year (n=17) were invited for repeat spirometry and assessment of changes in dyspnea level using the Transition Dyspnea Index (TDI).

RESULTS

Mean follow-up was 4.9 years (range 1.2-8.7). All spirometry variables showed significant improvement. Mean vital capacity (VC) in seated position improved from 70% (of predicted value) to 79% (p<00.03), and in supine position from 54% to 73% (p=0.03). Forced expiratory volume in 1s (FEV1) in supine position improved from 45% to 63% (p=0.02). Before surgery the mean decline in VC changing from seated to supine position was 32%. At follow-up this had improved to 9% (p=0.004). For FEV1 these values were 35% and 17%, respectively (p<0.02). TDI showed remarkable improvement of dyspnea (mean+5.69 points on a scale of -9 to +9).

CONCLUSION

Diaphragm plication for single- or double-sided diaphragm paralysis provides excellent long-term results. Most patients were severely disabled before surgery but could return to a more or less normal way of life afterwards.

Surgical Treatment for Empyema Thoracis: Is Video-Assisted Thoracic Surgery “Better” Than Thoracotomy?

BACKGROUND

Operations for empyema thoracis are conventionally performed by open thoracotomy, whereas the video-assisted thoracic surgery (VATS) approach remains controversial. This study compares the radiologic and functional outcomes of decortication using the two approaches.

METHODS

During a 5-year period, 77 consecutive patients underwent decortication for empyema thoracis at two university teaching hospitals. The choice of surgical approach was decided by surgeon preference. Preoperative and postoperative empyema management was the same in all patients. Postoperative radiologic improvements were graded by a radiologist blinded to the approach used. Functional improvements were assessed by a questionnaire-based survey conducted at a mean of 36 months after the surgical procedure.

RESULTS

The VATS approach was used in 41 patients and the thoracotomy approach in 36 patients. Patients in the two groups had similar preoperative demographic and clinical features. No patients required conversion from VATS to thoracotomy or reintervention for empyema. Intraoperative blood loss, duration of chest drain, lengths of hospital stay, and postoperative complication rates were all similar in the two groups. The mean operation time in the VATS group was significantly shorter (2.5 versus 3.8 hours, p < 0.001). Decortication using both approaches gave similar degrees of postoperative radiologic and functional improvements. Of the 42 patients available for follow-up, the 21 who received the VATS approach reported significantly less postoperative pain (p = 0.04), greater satisfaction with the wounds (p < 0.0001), and greater satisfaction with the operation overall (p = 0.006).

CONCLUSIONS

VATS allows equally effective decortication for empyema as thoracotomy. However, the VATS approach gives less pain and greater patient acceptance.

A novel instrumented retractor to monitor tissue-disruptive forces during lateral thoracotomy

OBJECTIVE

Acute and chronic pain after thoracotomy, post-thoracotomy pain syndrome, is well documented. The mechanical retractors used for the thoracotomy exert significant forces on the skeletal cage. Our hypothesis was that instrumented retractors could be developed to enable real-time monitoring and control of retraction forces. This would provide equivalent exposure with significantly reduced forces and tissue damage and thus less post-thoracotomy pain.

METHODS

A novel instrumented retractor was designed and fabricated to enable real-time force monitoring during surgical retraction. Eight mature sheep underwent bilateral thoracotomy. One lateral thoracotomy was retracted at a standard clinical pace of 5.93 +/- 0.80 minutes to 7.5 cm without real-time monitoring of retraction forces. The other lateral thoracotomy was retracted to the same exposure with real-time visual force feedback and a consequently more deliberate pace of 9.87 +/- 1.89 minutes (P = .006). Retraction forces, blood pressure, and heart rate were monitored throughout the procedure.

RESULTS

Full lateral retraction resulted in an average force of 102.88 +/- 50.36 N at the standard clinical pace, versus 77.88 +/- 38.85 N with force feedback (a 24.3% reduction, P = .006). Standard retraction produced peak forces of 450.01 +/- 129.58 N, whereas force feedback yielded peak forces of 323.99 +/- 127.79 N (a 28.0% reduction, P = .009). Systolic blood pressure was significantly higher during standard clinical retraction (P = .0097), and rib fracture occurrences were reduced from 5 to 1 with force feedback (P = .04).

CONCLUSIONS

Use of the novel instrumented retractor resulted in significantly lower average and peak retraction forces during lateral thoracotomy. Moreover, these reduced retraction forces were correlated with reductions in animal stress and tissue damage, as documented by lower systolic blood pressures and fewer rib fractures.

Chronic Pain in the Cancer Survivor: A New Frontier

OBJECTIVE

This monograph is intended to clarify the clinical problem of chronic pain in cancer patients.

DESIGN

A pertinent literature review on chronic pain syndromes in cancer patients was undertaken using Medline. Further, the treatment strategies for cancer versus chronic pain are contrasted and clarified.

RESULTS

With increasing cancer survivorship come new challenges in patient care. In the United States, the cancer-related death rate has dropped by 1.1% per year from 1993-2002. Seventy-five percent of children and two out of three adults will survive cancer, whereas 50 years ago just one out of four survived. The net effect of these trends and opportunities is a large and rapidly growing population of persons living longer with cancer and/or as cancer survivors. While agreement exists on the best strategies for assessment and treatment of most acute cancer pain syndromes, little consensus exists on the treatment of chronic pain in the patient with slowly progressive cancer or the cancer survivor.

CONCLUSIONS

The landscape of "cancer pain" is shifting quickly into a chronic pain situation in many instances, thereby blurring previous lines of distinction in treatment strategies most suited for "chronic" versus "malignant" pain. Adopting chronic pain treatment strategies including pharmacologic and other pain control techniques, rehabilitation care, and psychological coping strategies may lead to optimal outcomes. Lastly, as cancer evolves into a chronic illness, with co-morbid conditions, recurrent cancer, and treatment toxicities from repeated antineoplastic therapies, pain management challenges in the oncologic patient continue to increase in complexity.

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

OBJECTIVE

Studies in other surgical specialties have suggested that pre-emptive wound infiltration using a local anesthetic may reduce post-operative pain. We report the first randomized trial to assess the use of pre-emptive local anesthesia in video-assisted thoracic surgery (VATS).

METHOD

Thirty-one consecutive patients undergoing bilateral needlescopic VATS sympathectomy for palmar hyperhidrosis were studied prospectively. Each patient acted as their own control. For each patient, one side was randomized to receive 10ml 0.5% bupivicaine injected to the port sites before incision, and the contralateral control side to receive 10ml saline. Pain severity on a visual analog scale (VAS) was recorded for each chest side at 4h, 1 day and 7 days following surgery. All patients were blinded to the results of randomization throughout the study.

RESULTS

Follow up was complete for all patients. At 7 days after surgery, wound pain was significantly reduced by pre-emptive local anesthesia, with 10 (62.5%) of the 16 patients having residual pain reporting less pain on the pre-treated side (p=0.039). There was a trend for reduced pain on the pre-treated side at the other time points. Pain reduction by pre-emptive local anesthesia was not correlated with any demographic or clinical variable. Chest wall paresthesia distinct from localized wound pain was noted by six patients (19.4%), but was not reduced by pre-emptive local anesthesia. Overall, the post-operative discomforts felt by the patients after needlescopic VATS were mild, and did not cause significant functional disturbances.

CONCLUSION

Pre-emptive wound infiltration with a local anesthetic may reduce post-operative wound pain in needlescopic VATS procedures.

Regional Cancer Pain Syndromes

Cancer pain often presents in a body region. This review summarizes articles from 1999-2004 relevant to cancer pain syndromes in the head and neck, chest, back, abdomen, pelvis, and limbs. Although the evidence is limited, progress is being made in further development of the evidence base to support and guide current practice.

Chronic post-thoracotomy pain: a retrospective study

BACKGROUND

Chronic pain is common after thoracotomy. The primary goal of this study was to investigate the incidence of chronic post-thoracotomy pain. The secondary goal was to identify possible risk factors associated with the development of chronic post-operative pain.

METHODS

We contacted 255 patients who had undergone a classic postero-lateral thoracotomy at our institution in the period between January 2001 and December 2003. All patients received a letter requesting participation; a questionnaire was included with the letter. One week later patients were contacted by telephone to obtain the answers to the questionnaire.

RESULTS

We ultimately obtained results from 149 patients (58% of all thoracotomies, 84% of survivors). The overall incidence of chronic post-operative pain was 52% (32% mild, 16% moderate and 3% severe chronic post-operative pain). Patients with chronic post-operative pain reported acute post-operative pain more frequently than those without (85% vs. 62%, P = 0.01), had more severe acute post-operative pain (P = 0.0001), underwent more extensive surgical procedures (P = 0.01), had more constant acute pain (vs. fluctuating pain or pain in attacks) (P = 0.0004) and reported less absence of pain during the first post-operative week (P = 0.0001). There was no significant decrease in chronic pain with time after thoracotomy.

CONCLUSION

Our study confirms that chronic post-thoracotomy pain is a common problem. The results from our study suggest that chronic post-thoracotomy pain may be associated with more intensive and extensive nociceptive input due to thoracic surgery.

Long-term survivorship in lung cancer: a review

While outcome research in lung cancer has focused mainly on short-term survival and quality of life (QoL), information on long-term (ie, > 5 years postdiagnosis) lung cancer survivorship remains limited. This review addresses the epidemiologic significance of long-term lung cancer (LTLC) survivors, summarizes the current knowledge on their health and QoL, and suggests areas for further research in LTLC survivorship. Based on a small body of literature, lung cancer survivors do not experience the same quantity and QoL as their age-matched peers or as survivors of other cancers. Survival among 5-year survivors of lung cancer relative to the general US population with the same demographic characteristics is approximately 60%, and lung cancer survivors score lowest in health utility among long-term survivors of other cancers. Approximately one-quarter of long-term lung cancer (LTLC) survivors were significantly restricted in physical ability or reported significant depressive symptoms. There is a need to identify and intervene with subgroups of survivors who are at an elevated risk of premature death and diminished QoL. Lung cancer-specific survival alone does not reflect the overall illness burden in LTLC survivors. Patient care in lung cancer survivors should be continuous and comprehensive in considering multiple causes of health deterioration. Multidisciplinary research in epidemiologic, clinical, and basic science approaches is warranted to further our knowledge base for optimal long-term management and to develop the necessary intervention strategies among LTLC survivors.

Acupuncture is a feasible treatment for post-thoracotomy pain: results of a prospective pilot trial

Background

Thoracotomy is associated with severe pain that may persist for years. Acupuncture is a complementary therapy with a proven role in pain control. A randomized trial showed that acupuncture was effective in controlling pain after abdominal surgery, but the efficacy of this technique for the treatment of thoracotomy pain has not been established. We developed a novel technique for convenient application of acupuncture to patients undergoing thoracotomy, and in a Phase II trial evaluated the safety of this intervention and the feasibility of doing a randomized trial.

Methods

Adult patients scheduled for unilateral thoracotomy with preoperative epidural catheter placement received acupuncture immediately prior to surgery. Eighteen semi-permanent intradermal needles were inserted on either side of the spine, and four were inserted in the legs and auricles. Needles were removed after four weeks. Using a numerical rating scale, pain was measured on the first five postoperative days. After discharge, pain was assessed using the Brief Pain Inventory at 7, 30, 60 and 90 days.

Results

Thirty-six patients were treated with acupuncture. Of these, 25, 23, and 22 patients provided data at 30, 60, and 90 days, respectively. The intervention was well tolerated by patients with only one minor and transient adverse event of skin ulceration.

Conclusion

The rate of data completion met our predefined criterion for determining a randomized trial to be feasible (at least 75% of patients tolerated the intervention and provided evaluable data). This novel intervention is acceptable to patients undergoing thoracotomy and does not interfere with standard preoperative care. There was no evidence of important adverse events. We are now testing the hypothesis that acupuncture significantly adds to standard perioperative pain management in a randomized trial.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis

OBJECTIVES

For the past 60 years, successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) has been performed via a thoracotomy. However, a number of reports have described adverse musculoskeletal sequelae following thoracotomy in infants and young children. Until now, only a few scattered case reports have detailed an individual surgeon's success with thoracoscopic repair of EA/TEF. This multi-institutional review represents the largest experience describing the results with this approach.

METHODS

A cohort of international pediatric surgeons from centers that perform advanced laparoscopic and thoracoscopic operations in infants and children retrospectively reviewed their data on primary thoracoscopic repair in 104 newborns with EA/TEF. Newborns with EA without a distal TEF or those with an isolated TEF without EA were excluded.

RESULTS

In these 104 patients, the mean age at operation was 1.2 days (+/-1.1), the mean weight was 2.6 kg (+/-0.5), the mean operative time was 129.9 minutes (+/-55.5), the mean days of mechanical ventilation were 3.6 (+/-5.8), and the mean days of total hospitalization were 18.1 (+/-18.6). Twelve (11.5%) infants developed an early leak or stricture at the anastomosis and 33 (31.7%) required esophageal dilatation at least once. Five operations (4.8%) were converted to an open thoracotomy and one was staged due to a long gap between the 2 esophageal segments. Twenty-five newborns (24.0%) later required a laparoscopic fundoplication. A recurrent fistula between the esophagus and trachea developed in 2 infants (1.9%). A number of other operations were required in these patients, including imperforate anus repair in 10 patients (7 high, 3 low), aortopexy (7), laparoscopic duodenal atresia repair (4), and various major cardiac operations (5). Three patients died, one related to the EA/TEF on the 20th postoperative day.

CONCLUSIONS

The thoracoscopic repair of EA/TEF represents a natural evolution in the operative correction of this complicated congenital anomaly and can be safely performed by experienced endoscopic surgeons. The results presented are comparable to previous reports of babies undergoing repair through a thoracotomy. Based on the associated musculoskeletal problems following thoracotomy, there will likely be long-term benefits for babies with this anomaly undergoing the thoracoscopic repair.

Intercostal nerve mononeuropathy: study of 14 cases

This retrospective study describes 14 cases of intercostal nerve mononeuropathy (INM) found in 5,560 electromyography (EMG) exams performed between January 1991 and June 2004 in our University Hospital. Medical charts of all patients with history of thoracic pain and EMG diagnosis of intercostal mononeuropathy were reviewed. INM was detected in 14 patients; etiology was thoracic surgery in 6 (43%), post-herpetic neuropathy in 4 (28%), probable intercostal neuritis in 2 (14%), lung neoplasia in 1 (7%), and radiculopathy in 1 (7%). From this study, trauma and infection were the main etiologies in intercostal neuropathic pain development. Tricyclic antidepressants and anticonvulsants were the most common therapeutic drugs used.

Mid-Term Results After Thoracoscopic Transmyocardial Laser Revascularization

BACKGROUND

Transmyocardial revascularization is a surgical therapy for the relief of severe angina in patients who are not suitable candidates for coronary artery bypass graft surgery or percutaneous coronary interventions. Historically, surgical techniques employed a left thoracotomy with or without thoracoscopic assist for visualization. This study evaluated the feasibility and midterm outcomes after transmyocardial laser revascularization performed using a completely thoracoscopic, closed chest approach.

METHODS

Patients (9 men [90%] and 1 woman [10%]) at a mean age of 66 +/- 10 years who were ineligible for coronary artery bypass graft surgery or percutaneous coronary intervention underwent sole therapy transmyocardial laser revascularization using a completely thoracoscopic surgical approach using a holmium:yttrium-aluminum-garnet laser system. Preoperatively, patients had a mean ejection fraction of 0.51 +/- 0.09 and a mean angina class of 3.7 +/- 0.5.

RESULTS

A mean of 30 +/- 2.4 channels were created during mean laser and operative procedure times of 14 +/- 2.9 and 133 +/- 32 minutes, respectively. Patients were extubated at a mean of 7.6 +/- 12 hours and were discharged from the hospital at a mean of 5.4 +/- 3.4 days. There were no hospital deaths or major complications. At a mean of 8.4 +/- 5.5 months postoperatively, all patients survived and significant clinical improvement with a mean angina class of 1.3 +/- 0.5 (p < 0.001).

CONCLUSIONS

A completely thoracoscopic surgical approach is feasible for sole therapy transmyocardial revascularization that affords improved visualization over a limited thoracotomy approach. Limited complications and significant clinical improvement after the procedure were observed. With minimal port manipulation, there is an opportunity for decreased postoperative pain; however, larger studies are warranted to verify this hypothesis.

Chronic pain and thoracic surgery

The development of chronic pain after thoracic surgery is a particularly undesirable yet common complication. As the study of the pathophysiology of chronic pain with regard to the plasticity of the central nervous system advances, new insights are being gained into not only the potential origins of chronic postthoracotomy pain, but also its potential treatment options. Pain that is originally nociceptive in nature in the acute postoperative period after thoracotomy may become neuropathic in time, requiring a different paradigm for its treatment. The ongoing research into the development of chronic pain, including that observed after thoracic surgery, portends the development of further advances in options for its control. The employment of multidisciplinary strategies of pharmacologic, behavioral, and interventional procedural techniques provides the current foundation for the management of this challenging condition.

Characterization of a New Animal Model for Evaluation of Persistent Postthoracotomy Pain

Chronic pain after thoracotomy is common, although its basis and therapy have not been well characterized. In this study we characterize the allodynic responses (mechanical and cold) as well as the histopathologic changes after thoracotomy and rib retraction in rats. The antinociceptive effect of systemic and intrathecal analgesics was also evaluated. Male Sprague-Dawley rats were anesthetized and the right 4th and 5th ribs surgically exposed. The pleura was opened between the ribs and a retractor placed under both ribs and opened 8 mm. Retraction was maintained for 5, 30, or 60 min. Control animals had pleural incision only. Beginning Day 2 postsurgery, animals were tested for mechanical allodynia using calibrated von Frey filaments and cold allodynia using acetone applied to the incision site. Two weeks after surgery, animals were tested for reduction of allodynia with intraperitoneal and intrathecal injections of analgesics. Intercostal nerve histology was examined at 14 days postsurgery. Allodynia developed in 50% of the animals with 60 min retraction but in only 11% and 10% of animals when the retraction time was 5 and 30 min, respectively, and in none of the control animals. Allodynic animals showed extensive axon loss in the intercostal nerves of the retracted ribs. Allodynia appeared by Day 10 in the rib-retraction model and lasted at least 40 days. Systemic morphine sulfate (50% effective dose [ED(50)], 1.06 mg/kg) and gabapentin (ED(50), 24.2 mg/kg), as well as intrathecal morphine (ED(50), 1.19 nmol), gabapentin (ED(50), 13.8 nmol), clonidine (ED(50), 72.7 nmol), and neostigmine (ED(50), 0.54 nmol) reduced allodynia. Rib-retraction in rats for 60 min produces allodynia that lasts more than 1 mo, and this allodynia is reduced by morphine, gabapentin, clonidine, and neostigmine. This new model may be useful for quantifying the efficacy of techniques to reduce the frequency and severity of long-term postthoracotomy pain.

The utility and validity of the modified brief pain inventory in a multiple-dose postoperative analgesic trial

OBJECTIVES

Patients undergoing major surgery often require several days of postoperative analgesia. However, few data exist on the longitudinal course of postoperative pain and the psychometric properties of pain assessment tools used in this setting. Our objective was to validate use of the modified Brief Pain Inventory through reanalysis of pain data from a multiple-dose, placebo-controlled, randomized trial of analgesia after coronary artery bypass graft surgery.

METHODS

Four hundred sixty-two patients who underwent coronary artery bypass graft surgery via median sternotomy were administered a shortened form of the original Brief Pain Inventory that contained 3 severity and 5 interference items. Additionally, patients were presented with a single-item measure of procedure-specific pain. Daily pain and interference ratings were available from days 4 to 14 postoperatively. We performed factor analysis to evaluate the consistency with which the modified Brief Pain Inventory items loaded on 2 separate factors corresponding to the original Brief Pain Inventory's pain severity and pain interference subscales. We calculated 2 reliability measures, internal consistency and test-retest reliability, for each subscale.

RESULTS

The modified Brief Pain Inventory consistently measured 2 underlying constructs, severity and interference, with Cronbach alphas of 0.85 or greater for the 2 Brief Pain Inventory scales, and test-retest stability coefficients ranging from 0.58 to 0.95 for each pair of consecutive assessment periods. The procedure-specific pain question showed substantial overlap with a general measure of pain severity, suggesting concurrent validity.

DISCUSSION

The modified Brief Pain Inventory was stable and valid over the assessment period, suggesting that it can be used during the subacute postoperative period to assess postoperative pain among patients with coronary artery bypass graft surgery.

Postthoracotomy pain syndrome

Postthoracotomy pain syndrome is relatively common and is seen in approximately 50% of patients after thoracotomy. It is a chronic condition, and about 30% of patients might still experience pain 4 to 5 years after surgery. In the majority of patients pain is usually mild and only slightly or moderately interferes with normal daily living. In a small subset of patients pain can be severe and can be described as a true disability to the extent that these patients are incapacitated. The exact mechanism for the pathogenesis of PTPS is still not clear, but cumulative evidence suggests that it is a combination of neuropathic and nonneuropathic (myofascial) pain. Trauma to the intercostal nerve during thoracotomy is the most likely cause. Because pain does not cause disability in the majority of patients, management is usually conservative. If pain is causing disability then multidisciplinary pain management involving the pain specialist, social worker, physical therapist, and a psychologist is required. It is mandatory to exclude recurrence of disease or malignancy as a cause for the pain prior to initiating treatment. As with most forms of neuropathic pain, treatment of PTPS is also difficult and patients might require more than one form of therapy to control pain and reduce disability. Based on current evidence, it is not possible to draw any firm conclusion regarding whether any form of analgesic or surgical technique can influence the generation of PTPS. Preemptive analgesia initiated prior to surgery shows promise and might help reduce the incidence of PTPS. Scientific evidence is steadily growing but there is still a need for large, prospective, randomized trials evaluating PTPS. Until more is known about this condition and how to prevent the central and peripheral nervous system changes that produce long-term pain after thoracotomy, patients must be warned preoperatively about the possibility of developing PTPS and how it might affect their quality of life after surgery. In addition, measures such as selecting the least traumatic and painful surgical approach, avoiding intercostal nerve trauma, and adopting an aggressive multimodal perioperative pain management regimen commenced before the surgical incision should be performed to prevent postthoracotomy pain syndrome.

Neuropathic pain after femoropopliteal bypass surgery

OBJECTIVE

This retrospective study was performed to investigate prolonged postoperative pain in the area of the proximal or distal scar or the bypass tunnel after femoropopliteal bypass surgery to treat symptomatic peripheral arterial disease.

PATIENTS AND METHODS

Ninety-three patients with peripheral arterial disease who underwent femoropopliteal bypass surgery between January 2000 and December 2002 were included in the study. The short-form McGill Pain Questionnaire was used to score pain. Ultrasound examination of the soft tissue around the graft was performed to exclude other pathologic conditions responsible for pain, such as inflammatory processes, perigraft reactions, swollen lymph nodes, and hematomas.

RESULTS

Pain in at least one scar existed in 22 patients on average 13.9 +/- 9.8 months after surgery. In 10 patients pain existed simultaneously along the inguinal scar and the above-knee or below-knee scar. Pain along the bypass tunnel was experienced by seven patients. Most patients had mild to moderate pain. The mean numeric ranking score of pain severity in patients with pain was 4.2 +/- 2.3. The occurrence of prolonged postoperative pain was not associated with age, gender, diabetes, indication for surgery, material or type of bypass, number of preceding operations, or postoperative wound complications. Only follow-up time after femoropopliteal bypass surgery tended to be lower in patients with pain compared with those without pain.

CONCLUSION

Prolonged postoperative neuropathic pain along the distal and proximal incision or the bypass tunnel exists in one fourth of patients after femoropopliteal bypass surgery. Patients should be informed of this kind of complication before surgery. The results of our study justify further investigations of the origin and treatment of this pain, to find effective methods to reduce the incidence of prolonged postoperative pain after femoropopliteal bypass surgery.

Efficacy of transdermal nitroglycerin combined with etodolac for the treatment of chronic post-thoracotomy pain: an open-label prospective clinical trial

Chronic post-thoracotomy pain (CPP) is associated with surgical intercostal nerve injury. Like other forms of neuropathic pain, there is no ideal treatment. Nitroglycerin (NTG) has been found efficacious in acute pain, but has not been tested for chronic pain with neuropathic characteristics. The present study investigated the efficacy of NTG combined with the nonsteroidal anti-inflammatory drug etodolac for the treatment of CPP. Thirty of 129 patients who underwent thoracotomy within an 18-month period had moderate to severe pain that did not respond to etodolac. NTG, 5 mg/day, was added to the treatment. A significant reduction in VAS was observed on day 14 of treatment (from 66.7 +/- 11 to 42.1 +/- 5, P< 0.05). Similar changes were noted in breakthrough pain intensity and and sleep efficiency. The only side effect was mild headache, which was self-limited to the first few days of NTG administration. We conclude that NTG added to etodolac appears to be effective for the treatment of CPP, with minimal side effects. Further randomized blinded studies are required.

Diabetic thoracic radiculopathy: an unusual cause of post-thoracotomy pain

Persistent pain is common following thoracotomy. A 64-year-old retired electrician with Type 2 diabetes presented with chest wall and abdominal pain 3 months following video-assisted thoracoscopic surgery (VATS). Postoperatively the patient had suffered pain despite a functioning thoracic epidural catheter. Following investigation, his persistent pain was due to diabetic thoracic radiculopathy (DTR). The disorder is characterized by pain, sensory loss, abdominal and thoracic muscle weakness in patients with diabetes. As in this patient, the pain and sensory loss usually resolve within one year after onset. The disorder may be distinguished from intercostal neuralgia based upon clinical and electromyographic features.

Post-thoracotomy pain after thoracic epidural analgesia: a prospective follow-up study

BACKGROUND

Pain becomes chronic in 22-67% of patients who undergo a thoracotomy. Thoracic epidural analgesia (TEA) has replaced less invasive methods to manage postoperative pain. We wanted to find out if active use of TEA, combined with extended pain management at home, reduces the incidence of chronic post-thoracotomy pain.

METHODS

All consecutive thoracotomy patients during a 16-month period were included. On the ward, pain was measured daily by VAS during rest and coughing and the consumption of analgesics was registered. The patients were interviewed one week after discharge by telephone and by a questionnaire after 3 and 6 months to find out how much pain they had.

RESULTS

A total of 114 patients were recruited. The data were analysed from 89 patients who had had TEA and 22 who had had other methods. TEA was effective in alleviating pain at rest and during coughing. In the TEA patients the incidence of chronic pain of at least moderate severity was 11% and 12% at 3 and 6 months, respectively. One week after discharge 92% of all patients needed daily pain medication.

CONCLUSIONS

TEA seems effective in controlling evoked postoperative pain, but technical problems occurred in 24% of the epidural catheters. The incidence of chronic pain was lower compared with previous studies where TEA was not used. The patients had significant pain and needed regular pain medication and instructions during the first week after discharge. Extended postoperative analgesia up to the first week at home is warranted.

Acute pain management for patients undergoing thoracotomy

Management of thoracotomy pain can be difficult, but the benefits of effective pain control are significant. A variety of modalities for treating postoperative pain after thoracotomy are available, including systemic opiates, regional analgesics, and new oral and parenteral agents. This work provides a review of the literature and recommendations for the clinician.