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Maxwell CM, Weksler B, Houda J, Fernando HC. Intercostal Cryoablation During Video-Assisted Lung Resection Can Decrease Postoperative Opioid Use. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:352-356. [PMID: 37461202 DOI: 10.1177/15569845231185583] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVE Pain requiring opioid use remains an issue even with minimally invasive thoracic surgery. The objective of this study was to investigate the effectiveness of intercostal nerve cryoablation (CRYO) for pain control in adult patients undergoing pulmonary resection. METHODS A retrospective analysis of patients undergoing pulmonary resection by uniportal video-assisted thoracic (uVATS) approach was undertaken. Patients treated with our usual pain regimen (STANDARD) were compared with those who additionally received CRYO. STANDARD includes intercostal bupivacaine, patient-controlled analgesia (24 h), ketorolac (48 to 72 h), and tramadol. Intraoperative CRYO was performed on 5 intercostal levels. The primary aim was to compare pain scores (range, 0 to 10) and morphine equivalent dosages (MED). Secondary outcomes included length of stay, chest tube duration, presence of an air leak, and adverse events. A p value <0.05 was considered significant. RESULTS There were 49 patients (34 female, 15 male). The median age was 74 (37 to 90) years. Procedures included lobectomy (n = 32), segmentectomy (n = 7), and wedge resections (n = 10). There were 23 (46.9%) CRYO and 26 (53.1%) STANDARD patients. Baseline characteristics were similar. Mean length of stay (2.9 vs 3.5 days), chest tube duration (2.2 vs 1.8 days), and adverse events (9 of 23 vs 7 of 26) were similar. There were no complications attributable to CRYO. Pain scores were not significantly different on postoperative days (POD) 1 to 4. MED was significantly reduced after CRYO on POD 1 (5 vs 47.24), POD 2 (10.93 vs 25.04), POD 3 (8.13 vs 21.7), and POD 4 (7.08 vs 19.17). CONCLUSIONS CRYO can be performed safely during pulmonary resection and can decrease in-hospital opioid use. The results from this retrospective study will need to be validated in future prospective studies.
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Affiliation(s)
- Conor M Maxwell
- Department of General Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Benny Weksler
- Division of Thoracic and Esophageal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Joseph Houda
- Division of Thoracic and Esophageal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Hiran C Fernando
- Division of Thoracic and Esophageal Surgery, Allegheny Health Network, Pittsburgh, PA, USA
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2
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Makkad B, Heinke TL, Sheriffdeen R, Khatib D, Brodt JL, Meng ML, Grant MC, Kachulis B, Popescu WM, Wu CL, Bollen BA. Practice Advisory for Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients: Part 2. Anesth Analg 2023; 137:26-47. [PMID: 37326862 DOI: 10.1213/ane.0000000000006506] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pain after cardiac surgery is of moderate to severe intensity, which increases postoperative distress and health care costs, and affects functional recovery. Opioids have been central agents in treating pain after cardiac surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure. This Practice Advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee's Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of cardiac surgical patients. This Practice Advisory provides recommendations for providers caring for patients undergoing cardiac surgery. This entails developing customized pain management strategies for patients, including preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various cardiac surgical procedures. The literature related to this field is emerging, and future studies will provide additional guidance on ways to improve clinically meaningful patient outcomes.
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Affiliation(s)
- Benu Makkad
- From the Department of Anesthesiology, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Timothy Lee Heinke
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Raiyah Sheriffdeen
- Department of Anesthesiology, Medstar Washington Hospital Center, Washington, DC
| | - Diana Khatib
- Department of Anesthesiology, Weil Cornell Medical College, New York, New York
| | - Jessica Louise Brodt
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University, New York, New York
| | - Wanda Maria Popescu
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Christopher L Wu
- Department of Anesthesiology, Hospital of Special Surgery, Weill Cornell Medical College, New York, New York
| | - Bruce Allen Bollen
- Missoula Anesthesiology, Missoula, Montana
- The International Heart Institute of Montana, Missoula, Montana
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3
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Gabriel RA, Ilfeld BM. Extending Perioperative Analgesia with Ultrasound-Guided, Percutaneous Cryoneurolysis, and Peripheral Nerve Stimulation (Neuromodulation). Anesthesiol Clin 2022; 40:469-479. [PMID: 36049875 DOI: 10.1016/j.anclin.2022.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The use of regional anesthesia is key to a successful approach to improving postoperative analgesia, which involves local anesthetic deposition either around peripheral nerves or within a fascial plane. Unfortunately, the realistic duration even with continuous peripheral nerve blocks usually does not match the duration of surgical pain, comprising a major limitation. Here, the use of 2 interventional modalities-ultrasound-guided percutaneous cryoneurolysis and peripheral nerve stimulation-is discussed, both of which may be used to treat acute and subacute pain and may therefore have a positive impact on the incidence and severity of chronic pain development.
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Affiliation(s)
- Rodney A Gabriel
- Division of Regional Anesthesia and Acute Pain medicine, Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103-8990, USA
| | - Brian M Ilfeld
- Division of Regional Anesthesia and Acute Pain medicine, Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, San Diego, California 92103-8990, USA; Department of Anesthesiology, 9500 Gilman Drive, MC 0898, La Jolla, CA 92093-0898, USA.
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4
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Wong DH, Yost CC, Rosen JL, Wu M, Guy TS. Totally Endoscopic Robot-Assisted Aortic Valve Replacement and Complex Mitral Valve Repair: The Lateral Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:355-357. [PMID: 35770552 DOI: 10.1177/15569845221106939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 76-year-old male patient was referred to our institution with moderate-to-severe aortic and mitral insufficiency. The patient underwent totally endoscopic robot-assisted aortic valve replacement and mitral valve repair. In this article, we present our lateral approach to the robotic double valve surgery.
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Affiliation(s)
- Daniella H Wong
- 12313Sidney Kimmel Medical College, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Colin C Yost
- 12313Sidney Kimmel Medical College, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Jake L Rosen
- 12313Sidney Kimmel Medical College, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - Meagan Wu
- 12313Sidney Kimmel Medical College, 6559Thomas Jefferson University, Philadelphia, PA, USA
| | - T Sloane Guy
- Division of Cardiac Surgery, Department of Surgery, 23217Thomas Jefferson University Hospital, Philadelphia, PA, USA
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5
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Sherazee EA, Chen SA, Li D, Li D, Frank P, Kiaii B. Pain Management Strategies for Minimally Invasive Cardiothoracic Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:167-176. [PMID: 35521910 DOI: 10.1177/15569845221091779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Elan A Sherazee
- Department of Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Sarah A Chen
- Division of Cardiac Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - David Li
- Department of Anesthesiology and Pain Medicine, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - David Li
- Department of Pharmacy Services, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Paul Frank
- Department of Anesthesiology and Pain Medicine, 8789UC Davis Medical Center, Sacramento, CA, USA
| | - Bob Kiaii
- Division of Cardiac Surgery, 8789UC Davis Medical Center, Sacramento, CA, USA
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6
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Abstract
Chest wall pain affects many patients following chest surgery, fractures, or malignancies, and can be very difficult to manage with normal pharmacologic agents. Intercostal ablation provides one alternative treatment modality for patients suffering from intercostal pain. Intercostal cryoneurolysis involves using extreme cold to cause Wallerian degeneration of the targeted intercostal nerve. This article reviews the patient selection, technique, and complications in the utilization of intercostal neurolysis in the treatment of intractable chest pain.
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Affiliation(s)
- Junjian Huang
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kevin Delijani
- Georgetown University School of Medicine, Washington, District of Columbia
| | | | - Andrew J Gunn
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
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Choi J, Min JG, Jopling JK, Meshkin S, Bessoff KE, Forrester JD. Intercostal nerve cryoablation during surgical stabilization of rib fractures. J Trauma Acute Care Surg 2021; 91:976-980. [PMID: 34446656 DOI: 10.1097/ta.0000000000003391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intercostal nerve cryoablation (IC) offers potential for targeted and durable analgesia for patients with traumatic rib fractures. Our pilot study aimed to investigate thoracoscopic IC's safety, feasibility, and preliminary efficacy for patients undergoing surgical stabilization of rib fractures (SSRF). We hypothesized that concurrent surgical stabilization of rib fractures and intercostal nerve cryoablation (SSRF-IC) is a safe and feasible procedure without immediate or long-term complications. METHODS We retrospectively evaluated patients 18 years or older who underwent SSRF (with or without IC) for acute rib fractures at our level I trauma center between September 1, 2019, and September 30, 2020. We performed IC under thoracoscopic visualization (-70°C for 2 minutes per intercostal nerve bundle). Among patients whose only operative procedure during hospitalization was SSRF, we evaluated post-SSRF length of stay, operative times, opioid requirements (oral morphine equivalents), and pain scores (Numerical Rating Scale). Generalized estimating equations compared SSRF and SSRF-IC group outcomes (population mean [robust standard error]). We assessed long-term outcomes of patients who underwent SSRF-IC. RESULTS Thirty-four patients (144 ribs) underwent SSRF; of these, 20 patients (135 ribs) underwent SSRF-IC. Patients who did and did not undergo concurrent IC had no significant difference demographic, injury, or hospitalization characteristics. Among 20 patients who did not undergo other operations, 12 underwent SSRF-IC. We did not find significant difference between SSRF and SSRF-IC groups' median operative times or post-SSRF length of stay. Compared with SSRF group, SSRF-IC group did not have statistically significant change in pain score (0.2 [1.5] lower) or opioid use (43.9 [86.1] mg/d greater) between 12 hours before SSRF and last 24 admission hours. Among 17 SSRF-IC patients who followed-up postdischarge (median [range], 160 [9-357] days), one reported mild chest wall paresthesia; no other complications were reported. CONCLUSION This pilot study performing 135 intercostal nerve cryoablations on 20 patients suggests that IC is safe and feasible for patients undergoing SSRF. Evaluating IC's analgesic efficacy for rib fractures requires further study. LEVEL OF EVIDENCE Therapeutic, Level V.
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Affiliation(s)
- Jeff Choi
- From the Division of General Surgery, Department of Surgery (J.C., J.K.J., S.M., K.E.B., J.D.F.), Surgeons Writing About Trauma (J.C., J.G.M., J.K.J., S.M., K.E.B., J.D.F.), and School of Medicine (J.G.M.), Stanford University, Stanford, California
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8
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Krakowski JC, Hallman MJ, Smeltz AM. Persistent Pain After Cardiac Surgery: Prevention and Management. Semin Cardiothorac Vasc Anesth 2021; 25:289-300. [PMID: 34416847 PMCID: PMC8669213 DOI: 10.1177/10892532211041320] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Persistent postoperative pain (PPP) after cardiac surgery is a significant complication that negatively affects patient quality of life and increases health care system burden. However, there are no standards or guidelines to inform how to mitigate these effects. Therefore, in this review, we will discuss strategies to prevent and manage PPP after cardiac surgery. Adequate perioperative analgesia may prove instrumental in the prevention of PPP. Although opioids have historically been the primary analgesic approach to cardiac surgery, an opioid-sparing strategy may prove advantageous in reducing side effects, avoiding secondary hyperalgesia, and decreasing risk of PPP. Implementing a multimodal analgesic plan using alternative medications and regional anesthetic techniques may offer superior efficacy while reducing adverse effects.
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Affiliation(s)
| | | | - Alan M Smeltz
- University of North Carolina at Chapel Hill, NC, USA
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9
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Cha PI, Min JG, Patil A, Choi J, Kothary NN, Forrester JD. Efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain after surgery or trauma: systematic review. Trauma Surg Acute Care Open 2021; 6:e000690. [PMID: 34079913 PMCID: PMC8137159 DOI: 10.1136/tsaco-2021-000690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/04/2021] [Accepted: 04/24/2021] [Indexed: 11/03/2022] Open
Abstract
Background There is a critical need for non-narcotic analgesic adjuncts in the treatment of thoracic pain. We evaluated the efficacy of intercostal cryoneurolysis as an analgesic adjunct for chest wall pain, specifically addressing the applicability of intercostal cryoneurolysis for pain control after chest wall trauma. Methods A systematic review was performed through searches of PubMed, EMBASE, and the Cochrane Library. We included studies involving patients of all ages that evaluated the efficacy of intercostal cryoneurolysis as a pain adjunct for chest wall pathology. Quantitative and qualitative synthesis was performed. Results Twenty-three studies including 570 patients undergoing cryoneurolysis met eligibility criteria for quantitative analysis. Five subgroups of patients treated with intercostal cryoneurolysis were identified: pectus excavatum (nine studies); thoracotomy (eight studies); post-thoracotomy pain syndrome (three studies); malignant chest wall pain (two studies); and traumatic rib fractures (one study). There is overall low-quality evidence supporting intercostal cryoneurolysis as an analgesic adjunct for chest wall pain. A majority of studies demonstrated decreased inpatient narcotic use with intercostal cryoneurolysis compared with conventional pain modalities. Intercostal cryoneurolysis may also lead to decreased hospital length of stay. The procedure did not definitively increase operative time, and risk of complications was low. Conclusions Given the favorable risk-to-benefit profile, both percutaneous and thoracoscopic intercostal cryoneurolysis may serve as a worthwhile analgesic adjunct in trauma patients with rib fractures who have failed conventional medical management. However, further prospective studies are needed to improve quality of evidence. Level of evidence Level IV systematic reviews and meta-analyses.
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Affiliation(s)
- Peter I Cha
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Jung Gi Min
- Stanford University School of Medicine, Stanford, California, USA
| | | | - Jeff Choi
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Nishita N Kothary
- Section of Interventional Radiology, Department of Radiology, School of Medicine, Stanford University, Stanford, California, USA
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10
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Finneran Iv JJ, Ilfeld BM. Percutaneous cryoneurolysis for acute pain management: current status and future prospects. Expert Rev Med Devices 2021; 18:533-543. [PMID: 33961531 DOI: 10.1080/17434440.2021.1927705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Conventional nerve blocks utilize local anesthetic drugs to provide pain relief for hours or days following surgery or trauma. However, postoperative and trauma pain can last weeks or months. Ultrasound-guided percutaneous cryoneurolysis is an anesthetic modality that offers substantially longer pain relief compared to local anesthetic-based nerve blocks.Areas covered: In this review, we discuss the history, mechanism of action, and use of ultrasound-guided percutaneous cryoneurolysis by anesthesiologists in the setting of acute pain management.Expert opinion: Ultrasound-guided percutaneous cryoneurolysis offers the potential to provide weeks or months of pain relief following surgery or trauma. Compared to continuous local anesthetic-based peripheral nerve blocks, currently the gold standard for providing long duration postoperative analgesia, cryoneurolysis has benefits that include: 1) longer duration measured in weeks or months rather than days; 2) no external reservoir of local anesthetic to be carried by the patient; 3) no risk of infection; and 4) no risk of catheter dislodgement. However, cryoneurolysis can induce a prolonged motor block in addition to the sensory block, decreasing the appropriate indications to those in which potential sensory and motor deficits are acceptable. Additionally, cryoneurolysis of multiple nerves can have a substantial time requirement relative to conventional nerve blocks.
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Affiliation(s)
- John J Finneran Iv
- Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, University of California San Diego, San Diego, California, USA
| | - Brian M Ilfeld
- Outcomes Research Consortium, Cleveland, Ohio, USA.,Department of Anesthesiology, University of California San Diego, San Diego, California, USA
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11
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Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain. Anesthesiology 2020; 133:1127-1149. [PMID: 32898231 DOI: 10.1097/aln.0000000000003532] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.
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12
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Fitzgerald MM, Bhatt HV, Schuessler ME, Guy TS, Ivascu NS, Evans AS, Ramakrishna H. Robotic Cardiac Surgery Part I: Anesthetic Considerations in Totally Endoscopic Robotic Cardiac Surgery (TERCS). J Cardiothorac Vasc Anesth 2020; 34:267-277. [DOI: 10.1053/j.jvca.2019.02.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 11/11/2022]
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13
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Saisho H, Tobinaga S, Yoshida S, Tanaka H. Surgical repair of Stanford type A acute aortic dissection with extreme tuberculosis-related mediastinal deviation. Interact Cardiovasc Thorac Surg 2019; 29:800-802. [PMID: 31369121 DOI: 10.1093/icvts/ivz172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 06/12/2019] [Accepted: 06/23/2019] [Indexed: 11/13/2022] Open
Abstract
In this article, we report on the case of an 85-year-old woman with a history of left pulmonary tuberculosis, who was referred for Stanford type A acute aortic dissection. A preoperative chest X-ray and computed tomography revealed extreme mediastinal deviation to the left. We decided to perform surgery with left rib-cross thoracotomy. This approach yielded excellent exposure of the aortic root, ascending aorta and aortic arch. Following an uneventful operative and postoperative course, the patient was discharged on the 21st postoperative day.
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Affiliation(s)
- Hiroyuki Saisho
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Satoru Tobinaga
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Shohei Yoshida
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
| | - Hiroyuki Tanaka
- Department of Surgery, Kurume University School of Medicine, Kurume, Japan
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14
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Gabriel RA, Ilfeld BM. Peripheral nerve blocks for postoperative analgesia: From traditional unencapsulated local anesthetic to liposomes, cryoneurolysis and peripheral nerve stimulation. Best Pract Res Clin Anaesthesiol 2019; 33:293-302. [PMID: 31785715 DOI: 10.1016/j.bpa.2019.06.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 02/01/2023]
Abstract
Peripheral nerve blocks (PNBs) using local anesthetics either via single injection or continuous perineural catheter have been the mainstay for regional anesthesia and are a vital component of postoperative multimodal opioid-sparing pain management. There are some limitations to PNBs, however, mainly its limited duration of action, but also risk of catheter-associated infection and dislodgements. Furthermore, local anesthetic-based blocks can induce sensory deficits and motor weakness, possibly increasing the risk of falling and/or decreasing the ability to participate in postoperative rehabilitation. In this review, we first discuss various local anesthetic-based PNB techniques for major surgery and then review newer modalities, including liposome bupivacaine, cryoanalgesia, and peripheral nerve stimulation; all of which may offer advantages over single and continuous local anesthetic-based PNBs.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA.
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California, 200 West Arbor Dr, MC 8770, San Diego, CA 92103, USA.
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15
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Gabriel RA, Ilfeld BM. Percutaneous peripheral nerve stimulation and other alternatives for perineural catheters for postoperative analgesia. Best Pract Res Clin Anaesthesiol 2019; 33:37-46. [DOI: 10.1016/j.bpa.2019.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/24/2022]
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Abstract
Maximizing analgesia is critical following joint arthroplasty because postoperative pain is a major barrier to adequate physical therapy. Continuous peripheral nerve blocks have been the mainstay for acute pain management in this population; however, this and similar techniques are limited by their duration of action. Cryoneurolysis and peripheral nerve stimulation are two methodologies used for decades to treat chronic pain. With the advent of portable ultrasound devices and percutaneous administration equipment, both procedures may now be suitable for treatment of acute pain. This article reviews these two modalities and their application to joint arthroplasty.
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Affiliation(s)
- Rodney A Gabriel
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA 92103, USA
| | - Brian M Ilfeld
- Department of Anesthesiology, University of California, San Diego, 200 West Arbor Drive, MC 8770, San Diego, CA 92103, USA.
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Gabriel RA, Finneran JJ, Asokan D, Trescot AM, Sandhu NS, Ilfeld BM. Ultrasound-Guided Percutaneous Cryoneurolysis for Acute Pain Management. ACTA ACUST UNITED AC 2017; 9:129-132. [DOI: 10.1213/xaa.0000000000000546] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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19
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Minatoya K, Seike Y, Itonaga T, Oda T, Inoue Y, Kawamoto N, Miura S, Tanaka H, Sasaki H, Kobayashi J. Straight incision for extended descending and thoracoabdominal aortic replacement: novel and simple exposure with rib-cross thoracotomy. Interact Cardiovasc Thorac Surg 2016; 23:367-70. [PMID: 27209533 DOI: 10.1093/icvts/ivw140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 04/04/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Spiral incision of the thoracic wall towards the tip of a scapula and approach through the sixth intercostal space has been a standard method for the replacement of thoracoabdominal and descending aortic aneurysms. However, the exposure of the proximal lesion of the aorta with the spiral incision is not always sufficient for patients with a lesion extending into the aortic arch. Patients with Marfan syndrome tend to have a flat chest, and exposure using left thoracotomy generally causes difficulty to operate on the aortic arch. METHODS Since May 2012, 47 patients (mean age 51.2 ± 16.1, range 9-79, 33 males) have received a novel incision for better exposure of the extended descending and thoracoabdominal aneurysm. A straight incision instead of the traditional spiral one was made from the axilla to the umbilical region and the fourth to sixth ribs were transected. The latissimus dorsi muscle and thoracodorsal artery were preserved, which could be a source for collateral circulation to the Adamkiewicz artery. There were two emergent operations for acute aortic dissection. Twenty-four patients (51%) had undergone previous proximal aortic operation, and 2 patients undergone debranched thoracic endovascular aneurysm repair of the aortic arch. Connective tissue disorders were diagnosed in 16 (34.0%) patients (Marfan syndrome 13, Loeys-Dietz syndrome 3). All surgeries were performed under profound hypothermia. RESULTS Seven patients underwent total descending aortic replacement, and the others had Type II thoracoabdominal aortic replacements. Three had partial aortic arch replacement, 5 had total aortic arch replacement and 3 had Y-grafting for the abdominal aorta concomitantly. Operation time was 567 ± 141 min and cardiopulmonary bypass time was 259 ± 60 min. Three patients had a major stroke (6.4%), and 1 had a minor stroke. There was no spinal cord complication among survivors. Hospital mortality rate was 4.3% (2/47). These 2 patients underwent thoracoabdominal aortic replacement, and had a major stroke. CONCLUSIONS This new exposure with straight incision with rib-cross thoracotomy provided excellent exposures for the long segment of the thoracoabdominal aorta, and it enabled extended replacement from the ascending aorta to the abdominal aorta.
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Affiliation(s)
- Kenji Minatoya
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tatsuya Itonaga
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tatsuya Oda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Naonori Kawamoto
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Syuhei Miura
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroshi Tanaka
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Mustola ST, Lempinen J, Saimanen E, Vilkko P. Efficacy of Thoracic Epidural Analgesia With or Without Intercostal Nerve Cryoanalgesia for Postthoracotomy Pain. Ann Thorac Surg 2011; 91:869-73. [DOI: 10.1016/j.athoracsur.2010.11.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 11/09/2010] [Accepted: 11/10/2010] [Indexed: 11/17/2022]
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21
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Moore W, Kolnick D, Tan J, Yu HS. CT guided percutaneous cryoneurolysis for post thoracotomy pain syndrome: early experience and effectiveness. Acad Radiol 2010; 17:603-6. [PMID: 20227306 DOI: 10.1016/j.acra.2010.01.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 01/15/2010] [Accepted: 01/10/2010] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to determine the effect of cryoablation on pain levels in patients with histories of post-thoracotomy pain syndrome. MATERIALS AND METHODS Eighteen patients were included in this retrospective review. Preprocedural and immediate postprocedural pain scores were recorded, as well as several months after the procedures. RESULTS The average preprocedural pain score was 7.5 +/- 2.0, which decreased to 1.2 +/- 1.9 immediately after the procedure. After a mean follow-up period of 51 days, the average pain score was 4.1 +/- 1.7. The difference between preprocedural and postprocedural pain scores was statistically significant by Wilcoxon's rank sum test. CONCLUSION Cryoneurolysis of the intercostal nerves statistically significantly decreased pain scores in patients with post-thoracotomy pain syndrome.
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Affiliation(s)
- William Moore
- Department of Radiology, Stony Brook University Medical Center, Stony Brook, NY 11794, USA
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22
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Sasaki H. Coronary artery bypass grafting without full sternotomy. Surg Today 2009; 39:929-37. [PMID: 19882313 DOI: 10.1007/s00595-009-3976-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 04/05/2009] [Indexed: 10/20/2022]
Abstract
Coronary artery bypass grafting is performed without full sternotomy in selected patients because it is less invasive. Left internal thoracic artery-left anterior descending artery bypass (LITA-LAD bypass) via a small left anterior thoracotomy is a well established procedure, which achieves good graft patency with low mortality and morbidity rates. Multiple revascularization is possible with a limited lateral thoracotomy or L-figure approach. Axillary-coronary bypass and right gastroepiploic artery-right coronary artery bypass (RGEA-RCA bypass) are alternative methods, especially for redo surgery, in selected patients.
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Affiliation(s)
- Hideki Sasaki
- Department of Cardiothoracic Surgery, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA
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23
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Bainbridge D, Cheng DCH. Minimally invasive direct coronary artery bypass and off-pump coronary artery bypass surgery: anesthetic considerations. Anesthesiol Clin 2008; 26:437-52. [PMID: 18765216 DOI: 10.1016/j.anclin.2008.03.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many new surgical technologies are being developed, with the overall aim of improving outcomes. One common feature of many new technologies is that they offer a safer approach than previous techniques; one of the greatest forces for change over the last 30 years is risk reduction. Cardiac surgery risk has been effectively undercut by percutaneous-based procedures, which have offered dramatic reductions in risk--at least in the short term. Beating heart techniques, whether minimally invasive direct coronary artery bypass (MIDCAB), off-pump coronary artery bypass surgery (OPCAB), or in other forms, such as percutaneous valve replacement, are likely to dramatically increase over the next decade. What role OPCAB and MIDCAB techniques will play in this new era is anyone's guess.
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Affiliation(s)
- Daniel Bainbridge
- Department of Anesthesia and Perioperative Medicine, University of Western Ontario, University Hospital-LHSC, 339 Windermere Road, C3-172, London, Ontario, Canada.
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Ak K, Aybek T, Wimmer-Greinecker G, Ozaslan F, Bakhtiary F, Moritz A, Dogan S. Evolution of surgical techniques for atrial septal defect repair in adults: A 10-year single-institution experience. J Thorac Cardiovasc Surg 2007; 134:757-64. [PMID: 17723830 DOI: 10.1016/j.jtcvs.2007.04.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2007] [Revised: 03/29/2007] [Accepted: 04/09/2007] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We retrospectively analyzed our experience in atrial septal defect repair with varied minimally invasive surgical approaches. METHODS From 1997 to 2006, 64 patients underwent surgical repair of atrial septal defects in our center. Patients were grouped into four groups according to the approach used; group 1 (n = 16), partial lower sternotomy; group 2 (n = 20), right anterior small thoracotomy with transthoracic clamping; group 3 (n = 4), right anterior small thoracotomy with endoaortic balloon clamping; and group 4 (n = 24), totally endoscopic approach with the use of the da Vinci surgical system (Intuitive Surgical, Mountain View, Calif). Preoperative diagnosis was a large secundum type atrial septal defect in 60 patients, primum type in 3 patients, and sinus venosus type in 1 patient. RESULTS Complete atrial septal defect closure was verified by intraoperative transesophageal echocardiography in all patients. There was neither perioperative mortality nor major complication. Groups 3 and 4 had significantly longer aortic crossclamp, cardiopulmonary bypass, and skin-to-skin operative times than had groups 1 and 2 (P = .000). All groups had similar ventilation time, postoperative drainage, and intensive care unit and hospital stays. Only 2 patients in group 4 were converted to the minithoracotomy owing to endoaortic balloon failure. During the follow-up of 30 +/- 24.3 months, 1 patient in group 3 was reoperated on owing to significant residual shunting. CONCLUSIONS All types of atrial septal defects can be repaired via those four different approaches as safely as can be done by the conventional technique. General complications during surgical procedures are negligible. These approaches may be considered a standard treatment and an adjunct to transcatheter treatment options in atrial septal defect repair.
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Affiliation(s)
- Koray Ak
- Department for Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt/Main, Germany.
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25
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Falk V, Jacobs S, Gummert J, Walther T. Robotic coronary artery bypass grafting (CABG)—the Leipzig experience. Surg Clin North Am 2003; 83:1381-6, ix. [PMID: 14712873 DOI: 10.1016/s0039-6109(03)00165-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Technical and anatomical limitations as well as human factors complicate endoscopic coronary bypass surgery. Computer-enhanced telemanipulation systems overcome some of these shortcomings by restoring the dexterity and precision of a distant operator (surgeon) within a confined space. Endoscopic coronary artery bypass grafting (CABG) has evolved from a merely experimental approach to a clinical concept. Although CABG was initially exclusively performed on the arrested heart, adjunct technologies such as endoscopic vacuum-assisted stabilizers now allow a closed-chest, beating-heart procedure. The development of anastomotic devices, and further refinements in telemanipulator technology, optical systems, and image-guided augmented-reality scenarios will greatly facilitate endoscopic bypass grafting in the future.
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Affiliation(s)
- Volkmar Falk
- Department of Cardiac Surgery, Heart Center, University of Leipzig, Strümpellstrasse 39, 04289 Leipzig, Germany.
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Falk V, Jacobs S, Gummert JF, Walther T, Mohr FW. Computer-enhanced endoscopic coronary artery bypass grafting: the da Vinci experience. Semin Thorac Cardiovasc Surg 2003. [DOI: 10.1016/s1043-0679(03)70018-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Abstract
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.
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Affiliation(s)
- Roy G Soto
- Department of Anesthesiology, University of South Florida College of Medicine, Tampa, Florida 33612, USA.
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Abstract
Somatosensory evoked potentials (SEP) and sensory conduction velocity (SCV) were measured in rabbit sciatic nerves following graded cold lesioning. The SEP disappeared when injury was induced at temperatures below -60 degrees C, but returned on day 41+/-4 (mean+/-SD). SEP returned on day 56+/-11 days when the lesion was induced at 100 to -180 degrees C. The SEP latency was prolonged after creating lesions at -100 to -180 degrees C, compared with both the sham operated and the -20 degrees C groups. These experiments suggest the cryolesions produced at temperatures between -60 and -100 degrees C are most suitable for altering the electrophysiological conduction of the nerve, and may result in suitable post-operative analgesia.
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Affiliation(s)
- Linqiu Zhou
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania, 3400 Spruce Street, 5 West Gate Building, Philadelphia, PA 19104, USA.
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Bucerius J, Metz S, Walther T, Falk V, Doll N, Noack F, Holzhey D, Diegeler A, Mohr FW. Endoscopic internal thoracic artery dissection leads to significant reduction of pain after minimally invasive direct coronary artery bypass graft surgery. Ann Thorac Surg 2002; 73:1180-4. [PMID: 11996260 DOI: 10.1016/s0003-4975(02)03385-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The aim of this study was to evaluate postoperative pain levels after endoscopic versus conventional internal thoracic artery (ITA) dissection for minimally invasive direct coronary artery bypass graft surgery (MIDCABG) surgery. Results were compared with pain levels associated with conventional cardiac bypass operations through a median sternotomy. METHODS Of 190 patients included in this prospective study, 24 patients had endoscopic ITA takedown (MIDCABG-endo) using the da Vinci telemanipulator followed by a manual coronary anastomosis through a left minithoracotomy. A conventional MIDCABG operation (MIDCABG-conv) was performed in 73 patients with ITA preparation under direct vision. Postoperative pain levels after conventional CABG through a median sternotomy (CABG-conv, n = 93) served as controls. A standarized questionnaire including visual analog scale (VAS) was used for prospective pain assessment from POD 1 to 7. RESULTS Pain levels (VAS) declined in all groups from POD 1 to 7. Overall pain levels were significantly lower in the MIDCABG-endo group as compared with MIDCABG-conv and CABG-conv groups, respectively (p < 0.001, general linear model). There was no significant difference between the MIDCABG-conv and CABG-conv (p = not significant, general linear model) groups. Furthermore, patients after MIDCABG-endo required fewer nonsteroidal anti-inflammatory drugs and opioid medications, postoperatively. CONCLUSIONS An endoscopic ITA takedown in MIDCABG surgery leads to significantly reduced postoperative pain levels possibly because of less rib retraction.
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Affiliation(s)
- Jan Bucerius
- Department of Cardiac Surgery, Heartcenter, University of Leipzig, Germany.
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31
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Bucerius J. Amelioration of postthoracotomy pain: Reply. Ann Thorac Surg 2001. [DOI: 10.1016/s0003-4975(01)03141-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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32
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Lee ME. Amelioration of postthoracotomy pain. Ann Thorac Surg 2001; 72:2180. [PMID: 11789832 DOI: 10.1016/s0003-4975(01)03140-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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