A Meta-Analysis Comparing Muscle-Sparing and Posterolateral Thoracotomy

Comparison of long-term outcome between muscle sparing and non-muscle sparing surgical techniques in rib plating

PURPOSE

Surgical stabilization of rib fractures is an internationally established method for treating traumatic chest wall injuries. Few studies have compared the various surgical methods used. The aim of this study was to examine how different surgical methods affect long-term outcomes.

METHOD

This is a study of prospectively included patients with flail chest undergoing muscle-sparing chest wall surgery (n = 40) who were compared to historical controls who underwent conventional surgery with non-muscle-sparing incisions and thoracotomy (n = 38). The cohorts differed regarding injury severity, smoking habits and number of ribs operated. This was adjusted for using multiple linear regression. The primary endpoint was lung function, secondary endpoints were respiratory muscle strength, respiratory movement, physical function, physical activity, and quality of life (QoL) after six and 12 months.

RESULTS

Seventy-eight patients (67.9% men and 32.1% women) with a mean age of 63.6 ± 14.0 years were included. The predicted forced vital capacity (FVC) was 92.3 ± 14.3% vs. 85.0 ± 15.3% after 12 months (p = 0.037) in the muscle-sparing and conventional surgery cohorts, respectively. Shoulder movement (Boström Index 59 vs. 56, p = 0.007) and lateral flexion (16.1 vs. 11.4 cm, p = 0.004) were significantly better in the muscle-sparing surgery patients than the conventional surgery patients after one year. No significant differences were found in respiratory muscle strength, respiratory movement, physical activity, or QoL.

CONCLUSION

Patients who undergo muscle-sparing surgery for chest wall injury have better long-term lung function, shoulder movement, and thoracic movement than patients who undergo conventional surgery. No difference was found between the groups concerning self-reported outcome. Registered in www.

CLINICALTRIALS

gov at 2020-12-18 with the ID NCT04710602.

Muscle-sparing Vertical Thoracotomy in Children and Adolescents

BACKGROUND

Traditional posterolateral thoracotomy (PLT) is a painful and potentially morbid operation associated with an extensive recovery and a long, unsightly scar. In contrast, vertical thoracotomy (VT) is designed to spare muscles, avoid skin flaps, and minimize incision length, thereby limiting postoperative pain, hastening recovery, and improving scar cosmesis.

METHODS

We reviewed children aged 1-21 that underwent PLT and VT at our institution from 1/1/2013-12/1/2023. We analyzed demographic data, operative details, and clinical outcomes with special attention paid to total oral morphine equivalents (OME), time to ambulation, and wound complications.

RESULTS

We identified 105 patients who underwent PLT and 74 who underwent VT. Both groups were heterogeneous with a greater proportion of oncology patients that received wedge resection in the VT group and congenital lung lesions that received lobectomy in the PLT group. VT patients tended to be older and heavier than PLT patients. Patients who underwent VT demonstrated improved time to ambulation (1.4 ± 0.3 vs 3.0 ± 1.4 days, p = 0.037) and oral morphine equivalent requirements (1.4 ± 0.4mgOME/kg vs 3.5 ± 1.8mgOME/kg, p = 0.035) compared to those who underwent PLT. Additionally, no patients in the VT group required division of the serratus or latissimus, compared to 8 (8%) in the PLT group (p = 0.004).

CONCLUSION

Muscle-sparing vertical thoracotomy provides excellent exposure for most intrathoracic pediatric operations, results in a cosmetically acceptable scar that is easily hidden by the upper arm, may reduce the frequency of division of the latissimus and serratus, and does not worsen time to ambulation or post-operative opioid requirements.

LEVEL OF EVIDENCE

III.

The Effects of Various Approaches to Lobectomies on Respiratory Muscle Strength, Diaphragm Thickness, and Exercise Capacity in Lung Cancer

BACKGROUND

The most common surgery for non-small cell lung cancer is lobectomy, which can be performed through either thoracotomy or video-assisted thoracic surgery (VATS). Insufficient research has examined respiratory muscle function and exercise capacity in lobectomy performed using conventional thoracotomy (CT), muscle-sparing thoracotomy (MST), or VATS. This study aimed to assess and compare respiratory muscle strength, diaphragm thickness, and exercise capacity in lobectomy using CT, MST, and VATS.

METHODS

The primary outcomes were changes in respiratory muscle strength, diaphragm thickness, and exercise capacity. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were recorded for respiratory muscle strength. The 6-min walk test (6MWT) was used to assess functional exercise capacity. Diaphragm thickness was measured using B-mode ultrasound.

RESULTS

The study included 42 individuals with lung cancer who underwent lobectomy via CT (n = 14), MST (n = 14), or VATS (n = 14). Assessments were performed on the day before surgery and on postoperative day 20 (range 17-25 days). The decrease in MIP (p < 0.001), MEP (p = 0.003), 6MWT (p < 0.001) values were lower in the VATS group than in the CT group. The decrease in 6MWT distance was lower in the MST group than in the CT group (p = 0.012). No significant differences were found among the groups in terms of diaphragmatic muscle thickness (p > 0.05).

CONCLUSION

The VATS technique appears superior to the CT technique in terms of preserving respiratory muscle strength and functional exercise capacity. Thoracic surgeons should refer patients to physiotherapists before lobectomy, especially patients undergoing CT. If lobectomy with VATS will be technically difficult, MST may be an option preferable to CT because of its impact on exercise capacity.

A Novel Technique for Muscle Flap Preservation in Posterolateral Muscle-Sparing Thoracotomy

SUMMARY

The muscle-sparing thoracotomy offers several benefits over the traditional posterolateral thoracotomy approach for surgically accessing the chest cavity. Some of the potential advantages of preserving the latissimus dorsi and serratus anterior muscles include both functional benefits and potential use of these muscles for future flap reconstruction. Nevertheless, the muscle-sparing thoracotomy technique has traditionally been described with a wide exposure and, as a result, a theoretically higher risk of seroma and hematoma formation due to the increased dead space. The authors propose a new approach to muscle-sparing thoracotomy to avoid the disadvantages of each technique. By defining two subcutaneous anatomical triangles that can be safely lifted without disrupting the latissimus dorsi and serratus anterior muscles' blood supply, this novel approach provides good exposure, preserves muscle flaps for future use, and minimizes dead space. As a result, this novel muscle-sparing thoracotomy technique has the potential to minimize postoperative complications and maximize patient outcomes.

Influence of muscle-sparing lateral thoracotomy on postoperative pain and lameness: A randomized clinical trial

OBJECTIVE

To assess and compare the magnitude of lameness and level of pain after muscle-sparing lateral thoracotomy (MSLT) and standard lateral thoracotomy (SLT) in dogs.

STUDY DESIGN

Randomized, blinded, prospective clinical study.

ANIMALS

Twenty-eight client-owned dogs.

METHODS

The latissimus dorsi muscle was retracted in the MSLT group and was transected in the SLT group. Gait was analyzed with a force plate, and the peak vertical force symmetry index (SI) was calculated within 24 hours before surgery, 3 days postoperatively, and 8 to 12 weeks postoperatively. Symmetry index and pain scores as measured by the Glasgow Composite Measure Pain Scale - Short Form were assessed as primary outcome measures.

RESULTS

The SI 3 days postoperatively was lower compared with the preoperative SI value in all dogs, consistent with lameness of the ipsilateral thoracic limb (P < .001). The absolute differences in preoperative and 3-day-postoperative SI provided evidence that this change was 3.1-fold greater after SLT compared with after MSLT (P = .009). Pain scores 1 day after surgery were lower after MSLT (1) compared with after SLT (2.5, P < .001).

CONCLUSION

Lateral thoracotomies caused postoperative pain and ipsilateral forelimb lameness, and both were reduced by sparing the latissimus dorsi.

CLINICAL SIGNIFICANCE

Sparing the latissimus dorsi should be considered to decrease immediate postoperative morbidity in dogs undergoing lateral thoracotomy.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Hybrid treatment of a giant thoracic aneurysm in a 38 year-old woman

A 38-year-old woman, with no comorbidities, presented to an outside institution with a 10-cm aortic arch and descending thoracic aortic aneurysm. After an aborted attempt at hybrid repair, she underwent successful, staged repair with zone 1 thoracic endovascular aortic repair and open aneurysmal sac revision. The patient made an uneventful recovery with computed tomographic evidence of complete aneurysmal exclusion. This case demonstrates many of the techniques and issues in the evolving field of aortic arch repair.

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.

Nowadays open-chest surgery in the era of fast-track management

In more than a century, approaches to perform thoracic surgical procedures have had profound changes. A milestone of those changes has been the advent of video-assisted techniques which rapidly evolved from minor diagnostic procedures to the performance by video-assisted thoracic surgery (VATS) of almost any major thoracic surgery. Nevertheless, indications remain for open chest procedures along with the fact that thoracotomy techniques have also evolved to minimally invasive ways, far different from the full thoracotomy of the past. This chapter reviews the evolution of open chest techniques and describes in detail present way to perform low invasiveness open chest surgery leading to excellent results through a mild postoperative course. Unsolved issues regarding the comparison of video-assisted and open techniques, particularly in lung cancer surgery are also considered.