Early and long-term complaints following video-assisted thoracoscopic surgery: evaluation in 173 patients

Higher Cardiovagal Baroreflex Sensitivity Predicts Increased Pain Outcomes After Cardiothoracic Surgery

Excessive postoperative pain can lead to extended hospitalization and increased expenses, but factors that predict its severity are still unclear. Baroreceptor function could influence postoperative pain by modulating nociceptive processing and vagal-mediated anti-inflammatory reflexes. To investigate this relationship, we conducted a study with 55 patients undergoing minimally invasive cardiothoracic surgery to evaluate whether cardiovagal baroreflex sensitivity (BRS) can predict postoperative pain. We assessed the spontaneous cardiovagal BRS under resting pain-free conditions before surgery. We estimated postoperative pain outcomes with the Pain, Enjoyment, and General Activity scale and pressure pain thresholds on the first (POD1) and second (POD2) postoperative days and persistent pain 3 and 6 months after hospital discharge. We also measured circulating levels of relevant inflammatory biomarkers (C-reactive protein, albumin, cytokines) at baseline, POD1, and POD2 to assess the contribution of inflammation to the relationship between BRS and postoperative pain. Our mixed-effects model analysis showed a significant main effect of preoperative BRS on postoperative pain (P = .013). Linear regression analysis revealed a significant positive association between preoperative BRS and postoperative pain on POD2, even after adjusting for demographic, surgical, analgesic treatment, and psychological factors. Moreover, preoperative BRS was linked to pain interfering with general activity and enjoyment but not with other pain parameters (pain intensity and pressure pain thresholds). Preoperative BRS had modest associations with postoperative C-reactive protein and IL-10 levels, but they did not mediate its relationship with postoperative pain. These findings indicate that preoperative BRS can independently predict postoperative pain, which could serve as a modifiable criterion for optimizing postoperative pain management. PERSPECTIVE: This article shows that preoperative BRS predicts postoperative pain outcomes independently of the inflammatory response and pain sensitivity to noxious pressure stimulation. These results provide valuable insights into the role of baroreceptors in pain and suggest a helpful tool for improving postoperative pain management.

Randomized Trial of Bupivacaine Versus Liposomal Bupivacaine in Minimally Invasive Lobectomy

BACKGROUND

The objective of this single-blind randomized study is to compare local infiltration of bupivacaine or liposomal bupivacaine (LipoB) in narcotic naïve patients undergoing minimally invasive lobectomy for early stage lung cancer.

METHODS

Adult patients without previous lung surgery undergoing minimally invasive lobectomy (robotic or thoracoscopic) for early stage lung cancer were randomly assigned to bupivacaine (with epinephrine 0.25%, 1:200 000) or LipoB 1.3%. Pain level was documented using the visual analog scale and morphine equivalents for narcotic pain medications. Inhospital treatment cost and pharmacy cost were compared.

RESULTS

The study enrolled 50 patients (bupivacaine, 24; LipoB, 26). The mean age of patients was 66 years, 94% were non-Hispanic white, and 48% were male. There was no difference in baseline characteristics and comorbidities. Duration of surgery (105 vs 137 minutes, P = .152), chest tube duration (49 vs 55 hours, P = .126), and length of stay (2.45 vs 3.28 days, P = .326) were similar between treatments. Inhospital morphine equivalents were 42.7 mg vs 48 mg (P = .714), and the median pain score was 5.2 vs 4.75 (P = .602) for bupivacaine vs LipoB, respectively. There was no difference in narcotic use at 2 to 4 weeks (57.1% [12 of 21] vs 54.5% [12 of 22], P = 1.00), and at 6 months (5.9% [1 of 17] vs 9.5% [2 of 21], P = 1.00) after surgery. The overall cost ($20 252 vs $22 775, P = .225) was similar; however, pharmacy cost for LipoB was higher ($1052 vs $596, P = .0001).

CONCLUSIONS

In narcotic naïve patients undergoing minimally invasive lobectomy, short-term narcotic use, postoperative pain scores, length of stay, and long-term narcotic use were similar between bupivacaine and LipoB.

Single port video-assisted thoracoscopic surgery for removal of a retained bullet in the lung parenchyma; A case report with literature review

Introduction and importance

For many years, thoracotomy has been considered as the standard approach for thoracic injuries. The aim of the current paper is to report a successful use of video assisted thoracoscopic surgery (VATS) as the first line approach for the removal of a bullet retained deep in the lung parenchymal tissue.

Case presentation

A 46-year-old male presented with a vague pain in the chest at the site of a penetrating bullet injury 26 years prior. Chest and native chest Computed Tomography scan (CT scan) showed a 22 mm foreign body inside the substance of the left lower lobe in the anterior segment. Decision was made to remove the foreign body using VATS. The surgery was performed through an uni-port. The left lower lobe was explored and the foreign body was found within the anterior segment. It was removed and the defect was sutured using Vicryl 2/0.

Clinical discussion

Although VATS has been established to be an accurate evaluating technique for direct evaluation of the chest wall, lung parenchyma, mediastinum and diaphragm, along with its effectiveness in successfully treating a variety of conditions, its use in thoracic trauma is still not well defined.

Conclusion

This report supports the use of VATS as an effective and minimally invasive approach in the removal of foreign bodies in lung parenchyma.

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Video-assisted thoracoscopic surgery (VATS) has been suggested as a lessor invasive procedure.

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It's use in thoracic trauma remains controversial.

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Loss of tactile sensation is a major obstacle.

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In this report, removal of a retained bullet in the lung parenchyma using VATS has been discussed.

Comparison of analgesic efficacy of the conventional approach and mid-transverse process to pleura approach of the paravertebral block in video-assisted thoracoscopy surgeries: A randomised controlled trial

Background and Aims

The paravertebral block (PVB) is an effective alternative to thoracic epidural analgesia for post-operative analgesia in thoracic surgeries. Despite the use of ultrasound in PVB, the search for a safer approach continues. This study was conducted to compare the analgesic efficacy of conventional and mid-transverse process to the pleura (MTP) approach of the PVB.

Methods

Forty patients aged between 18-60 years, posted for video-assisted thoracoscopic surgery, were enroled for this study. Patients were randomised into two groups using a random number table, and group allocation was done by the sealed opaque envelope method. One group received PVB by conventional approach (group CP). In contrast, patients in the other group (group MP) received PVB by the mid-transverse process to pleura (MTP) approach before induction of general anaesthesia under ultrasound guidance. The study's primary aim was to compare analgesic consumption in the first 24 hours. Secondary aims were comparing the Visual Analogue Scale (VAS) score, block performance time, dermatomal spread, haemodynamic parameters such as heart rate (HR), oxygen saturation (SpO₂), and non-invasive blood pressure (NIBP), patient satisfaction scores, and complications observed. Data were analysed using Statistical Package for the Social Sciences version 23.

Results

Demographic parameters, block performance time, and dermatomal distribution were comparable in both groups. We did not find any statistical difference in the analgesic consumption in the first 24 hours (P = 0.38), VAS at rest or on movement, complication rates, and patient satisfaction scores between the groups.

Conclusion

The MTP approach of the PVB is as effective as the conventional thoracic paravertebral approach for post-operative analgesia in video-assisted thoracoscopic surgeries.

Prospective validation of the RAPID clinical risk prediction score in adult patients with pleural infection: the PILOT study

BACKGROUND

Over 30% of adult patients with pleural infection either die and/or require surgery. There is no robust means of predicting at baseline presentation which patients will suffer a poor clinical outcome. A validated risk prediction score would allow early identification of high-risk patients, potentially directing more aggressive treatment thereafter.

OBJECTIVES

To prospectively assess a previously described risk score (the RAPID (Renal (urea), Age, fluid Purulence, Infection source, Dietary (albumin)) score) in adults with pleural infection.

METHODS

Prospective observational cohort study that recruited patients undergoing treatment for pleural infection. RAPID score and risk category were calculated at baseline presentation. The primary outcome was mortality at 3 months; secondary outcomes were mortality at 12 months, length of hospital stay, need for thoracic surgery, failure of medical treatment and lung function at 3 months.

RESULTS

Mortality data were available in 542 out of 546 patients recruited (99.3%). Overall mortality was 10% at 3 months (54 out of 542) and 19% at 12 months (102 out of 542). The RAPID risk category predicted mortality at 3 months. Low-risk mortality (RAPID score 0-2): five out of 222 (2.3%, 95% CI 0.9 to 5.7%); medium-risk mortality (RAPID score 3-4): 21 out of 228 (9.2%, 95% CI 6.0 to 13.7%); and high-risk mortality (RAPID score 5-7): 27 out of 92 (29.3%, 95% CI 21.0 to 39.2%). C-statistics for the scores at 3 months and 12 months were 0.78 (95% CI 0.71-0.83) and 0.77 (95% CI 0.72-0.82), respectively.

CONCLUSIONS

The RAPID score stratifies adults with pleural infection according to increasing risk of mortality and should inform future research directed at improving outcomes in this patient population.

[Thoracic Surgery: The Era of Minimally Invasive Lobectomy]

The contingent of VATS (video assistend thoracic surgery) lobectomies will continue to increase in the time to come. Thoracic surgery departments that do not integrate this procedure into their routine spectrum will have to justify themselves to referrers and clinic administrations and will have problems with the recruitment of training assistants as well. The advantages of minimally invasive lobectomy are impressive and the long-term oncological results are equivalent to open lobectomy. VATS lobectomies in non-intubated patients will increase significantly in the next few years and further reduce the invasiveness of the operation. The number of clinics that offer RATS (roboter assistend thoracic surgery) lobectomies will also increase as more companies bring robot systems onto the market, making them significantly cheaper. Better screening programs for risk patients for lung cancer, rapid advances in thoracic oncology and further minimization of surgical trauma in lung resections will significantly improve the overall therapy and prognosis for lung cancer patients in the years to come.

Diagnostic value and complication rate of ultrasound-guided transthoracic core needle biopsy in mediastinal lesions

BACKGROUND

Ultrasound-guided transthoracic core needle biopsy (US-TCNB) is a promising method for establishing the correct diagnosis of mediastinal masses. However, the existing studies in this area are scant and with small samples.

PURPOSE

To evaluate the diagnostic value and the complication rate of US-TCNB, particularly large bore cutting biopsy in patients with mediastinal lesions.

MATERIAL AND METHODS

This retrospective study includes 566 patients with mediastinal lesions suspicious of malignancy evaluated between March 2004 and December 2018. Inclusion criteria: 1. Patients with mediastinal lesions detected on thoracic CT scan; 2. Lesions more than 15 mm; 3. Negative histological diagnosis after bronchoscopic biopsy; 4. Normal coagulation status; 5. Cooperative patient; 6. Written informed consent. US visualization of the mediastinal lesions was successful in 308 (54.4%). In all of them, US-TCNB was performed. All patients with mediastinal lesions unsuitable for US visualization were evaluated for a CT-guided transthoracic needle biopsy (CT-TTNB), which was done if the presence of a safe trajectory was available (n = 41, 7.2%). All patients inappropriate for image-guided TTNB were referred to primary surgical diagnostic procedures (n = 217, 38.3%).

RESULTS

The US-TCNB is a highly effective (accuracy 96%, sensitivity 95%) and safe tool (2.6% complications) in the diagnosis of all subgroups mediastinal lesions. It is non-inferior to CT-TTNB (90%) and comes close to the effectiveness of surgical biopsy techniques (98.4%), but is less invasive and with a lower complication rate.

CONCLUSION

US-TCNB of mediastinal lesions is highly effective and safe tool which is particularly helpful in critically ill patients.

Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.

Contemporary best practice in the management of malignant pleural effusion

Malignant pleural effusion (MPE) affects more than 1 million people globally. There is a dearth of evidence on the therapeutic approach to MPE, and not surprisingly a high degree of variability in the management thereof. We aimed to provide practicing clinicians with an overview of the current evidence on the management of MPE, preferentially focusing on studies that report patient-related outcomes rather than pleurodesis alone, and to provide guidance on how to approach individual cases. A pleural intervention for MPE will perforce be palliative in nature. A therapeutic thoracentesis provides immediate relief for most. It can be repeated, especially in patients with a slow rate of recurrence and a short anticipated survival. Definitive interventions, individualized according the patient's wishes, performance status, prognosis and other considerations (including the ability of the lung to expand) should be offered to the remainder of patients. Chemical pleurodesis (achieved via intercostal drain or pleuroscopy) and indwelling pleural catheter (IPC) have equal impact on patient-based outcomes, although patients treated with IPC spend less time in hospital and have less need for repeat pleural drainage interventions. Talc slurry via IPC is an attractive recently validated option for patients who do not have a nonexpandable lung.

Prospective evaluation of chronic pain disorders and treatments

BACKGROUND

The incidence of chronic pain is variable among individuals who have sustained traumatic or surgical injury. Also, treatments for pain rarely are effective consistently for a procedure or agent, and no therapies are considered effective for pain that is chronic.

NEW METHOD

Difficulties with standard methods for conducting clinical trials call attention to a need for protocols that provide a new understanding of the development of and control over chronic pain. Prospective single-subject research designs can document varieties of pain progression over time for individuals. Subsequent grouping of individuals with common characteristics directs a mechanism-based approach to therapy.

RESULTS

Tracking of individuals' pain and associated influences over time is consistent with clinical practice, noting and adapting to changes that occur.

COMPARISON WITH EXISTING METHODS

Grouping patients with diverse characteristics and variable effects of therapy is problematic. Conventional evaluation of pain assesses patients with similar injuries or surgery without characterizations of individuals who develop chronic pain or recover over time. Also, classical evaluation of therapies involves comparison of groups receiving treatment or a placebo without characterization of patients with successful and unsuccessful results.

CONCLUSIONS

Single-subject prospective studies can inform clinical trials according to individual differences that would be obscured by comparison of groups with unknown variation in characteristics that influence pain and therapeutic effectiveness.

Effect of preoperative pregabalin as an adjunct to a multimodal analgesic regimen in video-assisted thoracoscopic surgery: A randomized controlled trial

BACKGROUND

Depending on the type of injury, the pain mechanisms are multifactorial. Preoperative pregabalin administrations as an adjunct to a multimodal postoperative pain management strategy have been tested in various surgical settings. The purpose of current study was to evaluate the effects of preoperative pregabalin administration on postoperative pain intensity and rescue analgesic requirement following video-assisted thoracoscopic surgery (VATS).

METHODS

Sixty adult patients undergoing VATS were randomly assigned either to receive pregabalin 150 mg (Pregabalin group) or placebo (Control group) 1 hour before anesthesia. Primary efficacy variable was pain intensity. Secondary efficacy variables were the requirement of rescue analgesics, total volume of intravenous patient-controlled analgesia (IV-PCA), and adverse effects induced by pregabalin or IV-PCA.

RESULTS

Pain intensity scores at post-anesthesia care unit (PACU), 6 and 24 hours were lower significantly in the Pregabalin group compared with the Control group (mean [SD]; 5.6 [2.0] vs 6.8 [1.8]; mean difference: 1.2, 95% CI of difference: 0.2166-2.1835, P = .018, mean [SD]; 3.8 [1.9] vs 5.6 [1.4]; mean difference: 1.8, 95% CI of difference: 1.0074-2.7260, P = .001 and mean [SD]; 2.6 [1.6] vs 3.5 [1.5]; mean difference: 0.9, 95% CI of difference: 0.0946-1.7054, P = .029, respectively]. Also, the frequency of additional rescue drug administered at PACU (median [interquartile range]; 2 [2-3] vs 1 [1-2], P = .027) was significantly less in the Pregabalin group. The incidences of adverse effects related to pregabalin or IV-PCA were not different between the groups.

CONCLUSION

A single administration of pregabalin 150 mg before VATS decreased postoperative pain scores and incidence of additional rescue analgesics in the immediate postoperative period without increased risk of adverse effects.

Surgical and non-surgical management of malignant pleural effusions

INTRODUCTION

Optimal management of malignant pleural effusion (MPE) is important in the care of patients with advanced cancer. Surgical (especially video-assisted thoracoscopic surgery (VATS)) and non-surgical strategies are available. Clinicians should be aware of the evidence supporting the use of different modalities to guide treatment choice. Areas covered: This review covers published evidence of the advantages and disadvantages of VATS and non-surgical alternatives for MPE management. Expert commentary: Randomized clinical trials (RCTs) are needed to define the roles and benefits of VATS as existing literature is often flawed by selection bias. Three RCTs have failed to show benefits of VATS talc poudrage over bedside talc pleurodesis. VATS-pleurectomy offered no survival advantage in a RCT of mesothelioma patients. Modification of VATS techniques has reduced the invasiveness and associated risks. Future trials should compare VATS with contemporary, non-surgical approaches (especially combined Indwelling Pleural Catheter (IPC) and chemical pleurodesis therapy). Individualized management for different subgroups of MPE patients should be a long-term research goal. Studies are needed on better patient selection, and adjunct non-invasive, supportive (e.g. nutrition and exercise) therapies.

CT-guided percutaneous hookwire localization increases the efficacy and safety of VATS for pulmonary nodules

BACKGROUND AND OBJECTIVES

The diagnosis of pulmonary nodules of unknown origin is challenging, and such nodules are not always suitable for transthoracic needle biopsy. With the advent of video assisted thoracic surgery (VATS) and CT-guided percutaneous hookwire localization (CT-PHL) we hypothesized that the combination of these two procedures will improve early diagnosis.

METHODS

Selection criteria were a nodule not well approachable with fine needle biopsy and the therapeutic consequences of a diagnosis as assessed by the multidisciplinary oncology board. Efficacy and safety of the combination of CT-PHL prior to VATS was studied in terms of, histological diagnosis, complete resection rate, complications, conversion rate to thoracotomy, and duration of procedures.

RESULTS

A total of 150 pulmonary nodules were located and resected in 150 patients. The median nodule diameter was 9 mm (range 4-24) and located within 30 mm of the pleural surface (median 7, range 0-29). The resection was complete in 96%, and in 100% a definitive histological diagnosis was obtained. Complications requiring intervention during the CT-procedure occurred in 11 patients (7.3%). Complications of VATS consisted of major complications (2.0%) and minor complications (4.0%). The 30 Day mortality was 1.4% and in hospital mortality 0.7%. Conversion to thoracotomy occurred in 4.7% patients. Median CT-localization time was 25 min (range 5-72), median VATS time was 49 min (range 14-169).

CONCLUSIONS

CT-PHL is a very efficient and safe procedure prior to VATS for pulmonary nodules and allows in 96% radical resection with a diagnostic accuracy of 100%.

Asian perspectives in thoracic surgery: clinical innovation in Taiwan

The development of minimally-invasive surgery of the thorax began in the 1990s, but not until the recent decade did we see dramatic improvements in patient care and refinement of technique. The current generation has witnessed the evolution from traditional thoracotomy, to a single-port, non-intubated thoracoscopic approach. The investigation of subxiphoid single-port, transumbilical approach, and natural orifice transluminal endoscopic surgery (NOTES) in animal model are also undergoing. In Taiwan, several talented young surgeons have vigorously devoted their ideas and innovations to this field, making the Taiwan surgical society vivid and prosperous. The desire to improve, and willingness to change are the foundation of those surgeons. Providing better patient care is their impetus to strive for improvement. This article provides an account of how minimally-invasive thoracic surgery has evolved in recent years, and what clinical innovations have been developed by the Taiwan surgical society.

A retrospective study of open thoracotomies versus thoracoscopic surgeries for persistent postthoracotomy pain

OBJECTIVE

Persistent thoracotomy pain syndrome (PTPS) is a recognized complication and is considered to be less after video-assisted thoracoscopic surgery (VATS) compared with open thoracic surgery (OTS). The primary objective was to compare the incidence of PTPS at 6 months. Secondary objectives were to compare the incidence of neuropathic pain between VATS and OTS and to report perioperative factors associated with the development of PTPS.

METHODS

This historical cohort study involved patient contact by a questionnaire regarding the presence of PTPS and its type. Patient, surgical, and analgesia factors were collected from health records, acute pain, and thoracic surgery databases. The data were analyzed using a multivariable logistic regression analysis, with results reported as adjusted odds ratio (OR) (95% confidence interval; P value).

RESULTS

Of 308 patients, 130 returned their questionnaire, and 106 responses were analyzed. The incidence of PTPS was 35% and 54% with VATS and OTS respectively, with an adjusted OR, 0.33 (95% confidence interval, 0.13-0.86), P= .024. The percentage of neuropathic pain was 18% and 48%, with VATS and OTS respectively, with an adjusted OR, 0.18 (0.04-0.85), P= .031. The diagnosis of cancer and previous chronic pain history were observed to be significantly associated with PTPS.

CONCLUSIONS

Our study indicates that PTPS is significantly more common and has a higher chance of being neuropathic with OTS. Despite being relatively less traumatic, VATS still carries a significant potential for PTPS. A diagnosis of cancer and history of previous pain are highly predictive of its development.

Sympathectomy for Palmar Hyperhidrosis

Palmar hyperhidrosis is an important situation that may cause emotional and work-related problems. Although local treatment and psychotherapy have been used for palmar hyperhidrosis, the choice of treatment for palmar hyperhidrosis is video-assisted thoracoscopic sympathectomy. Retrospective analysis of 120 bilateral thoracoscopic sympathectomies (60 patients) was done in this study. Earlier, 12 of 60 patients (20 %) had been operated on by other surgeons who used clipping method for palmar hyperhidrosis in different hospitals within 1 year. The procedure was performed under general anesthesia using single-lumen endotracheal tube. Sympathetic chain resection was performed between lower level of the second rib and upper level of the fourth rib. Intercostal blockage at three levels was performed, while thoracoscopic control of the injection sites was done. We observed improvement of symptoms in 95 %, mild compensatory sweating in 20 %, and excessive dryness of hands in 10 % in our patients.

One-port videothoracoscopic surgical intervention

BACKGROUND

One-port video-assisted thoracic surgery (VATS) has recently been proposed as an alternative to conventional 3-port VATS. To reduce pain, chest wall paresthesia, and hospital stay, lesser ports are the current direction.

MATERIALS AND METHODS

From 2007 to 2010, 98 patients underwent 1-port VATS procedure. The charts were retrospectively evaluated. A 2.5 cm long incision was made at the sixth intercostal space in the median axillary line. A single flexible port was used. Both the camera and the endoinstruments were introduced through the port. Patient characteristics, visual analog score, and postoperative paresthesia scores were evaluated.

RESULTS

The study enrolled 38 women and 60 men with the mean age of 49.1±1.5 years (range, 19 to 75 y). Thirty-one patients (28.6%) were diagnosed with malignant pleural effusion. Perioperative pleurodesis with talc was performed in 81% of them. One-port VATS approach was used for pleura biopsies in 77 (78.6%), wedge resection in 4 (3.8%), pleurectomy in 13 (12.4%), and biopsy with talc chemical pleurodesis in 4 (3.8%) instances. The mean operation time was 24.4 minutes (range, 15 to 50 min). No major cardiorespiratory or surgical complications were noted. The median observation time was 60 months (range, 36±81 mo). Among benign pathology patients, 56 (82.3%) of them did not complain about any pain; however, 12 patients had prolonged discomfort (2 pinprick, 6 numbness, and 4 pruritus).

CONCLUSIONS

One-port VATS in selected patients are feasible and seems to be safe in thoracic surgical interventions instead of conventional 3 ports that was presented in this series.

Transumbilical Thoracoscopy Versus Conventional Thoracoscopy for Lung Wedge Resection: Safety and Efficacy in a Live Canine Model

PURPOSE

Transumbilical single-port surgery has been associated with less postoperative pain and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. This study compares the safety and efficacy of transumbilical thoracoscopy and conventional thoracoscopy for lung wedge resection.

METHODS

The animals (n = 16) were randomly assigned to the transumbilical thoracoscopic approach group (n = 8) or conventional thoracoscopic approach group (n = 8). Transumbilical lung resection was performed via an umbilical incision and a diaphragmatic incision. In the conventional thoracoscopic group, lung resection was completed through a thoracic incision. For both procedures, we compared the surgical outcomes, for example, operating time and operative complications; physiologic parameters, for example, respiratory rate and body temperature; inflammatory parameters, for example, white blood cell count; and pulmonary parameters, for example, arterial blood gas levels. The animals were euthanized 2 weeks after the surgery for gross and histologic evaluations.

RESULTS

The lung wedge resection was successfully performed in all animals. There was no significant difference in the mean operating times or complications between the transumbilical and the conventional thoracoscopic approach groups. With regard to the physiologic impact of the surgeries, the transumbilical approach was associated with significant elevations in body temperature on postoperative day 1, when compared with the standard thoracoscopic approach.

CONCLUSIONS

This study suggests that both approaches for performing lung wedge resection were comparable in efficacy and postoperative complications.

Predictive value of systemic and local inflammation parameters in talc pleurodesis assessment

BACKGROUND

One option for the palliative treatment of recurrent malignant pleural effusion is powdered talc using thoracoscopy. This paper presents the results of selected systemic and local manifestations of the talc-induced inflammatory reaction using a videothoracoscope.

METHOD

A total of 114 patients with repeated malignant pleural effusion were treated at the Cardiac Surgery Clinic in Hradec Kralove from January 2010 to December 2012. Those with a life expectancy more than ≥ 3 months were eligible for talcage surgery. The group was retrospectively divided according to treatment results into Group A (N1 = 98 - successful) and Group B (N2 = 16 - relapsing). The pleural effusion was quantified using ultrasound over 1 year at 3-month intervals. Systemic changes due to the inflammatory reaction (body temperature, serum leukocyte and CRP levels) were evaluated. Local indicators of inflammation included changes in the leukocyte cell population in the effusion and changes in the pleural CRP levels. The dynamics of local expression of membrane receptors TLR-2 and CD-64 on granulocyte and monocyte cell populations in the pleural effusion were also evaluated.

RESULTS

The reaction after talcage, included a significant increase in axillary temperature and leukocyte count, 12 h after the procedure. The dynamics were different in the two groups. The dynamics of local inflammatory changes were an early increase in the pleural CRP levels in both groups. The time interval of local inflammatory development and duration was related to the treatment efficacy and showed a significant rise 2 h after talcage in Group A. In Group B the local inflammatory reaction was slower and the rise was only observed 24 h after talc application. A decrease in lymphocyte count and an increase in granulocyte count 2 h after talcage were found. After an initial drop in monocyte level, a rise occurred within 24 h after talcage. Changes in the expression of TLR-2 and CD-64 receptors in relation to their cell carriers were observed depending on time after talcage.

CONCLUSION

The differences in the serum and pleural effusion CRP levels suggest that the surgical stress manifests itself locally in the pleural space with a lower intensity and time delay. The TLR-2 and CD-64 receptors exhibit different behaviour depending on the type of cell membrane where they are found. The inverse relation between the granulocyte increase and TLR-2 receptor decrease in the membrane immediately after talcage is a new finding. The dynamics of TLR-2 expression on the monocytes demonstrates a direct proportion between the increasing expression of the TLR-2 receptor and increasing percent fraction of the cell carrier.

Bilateral single-port sympathectomy: long-term results and quality of life

Object. Video-assisted thoracoscopic sympathectomy is a safe, effective, and minimally invasive procedure for primary hyperhidrosis. This study aims to evaluate long-term results and patients' quality of life and investigate potential variables responsible for compensatory sweating after one-stage bilateral single-port thoracoscopic sympathectomy. Methods. Between 2005 and 2011, 260 consecutive bilateral thoracoscopic sympathectomies were performed in 130 patients for primary palmar and axillary hyperidrosis through one-port access. Residual pain, postoperative complications, recurrence of symptoms, heart rate adjustment, and quality of life were analyzed. Multivariate analysis was performed. Results. No operative mortality and conversion to open surgery were recorded. Mean operative time was 38 ± 5 minutes. Mean hospital stay was 1.1 ± 0.6 days. Eight patients (6%) had unilateral pneumothorax. Twenty-five cases (19%) were complicated by compensatory sweating. Winter and fall were identified as protective factors for compensatory sweating occurrence. Decreased heart rate was observed 1 year after surgery and permanently over the time. No recurrence during the follow-up period (31.5 months) was observed and 90% of patients showed improved quality of life. Conclusions. One-stage bilateral miniuniportal thoracoscopic sympathectomy is a valid and safe treatment for primary hyperhidrosis, achieving definitive and esthetic results, with excellent patients' satisfaction. Compensatory sweating may potentially occur in a season-dependent manner.

The neuropathic component in persistent postsurgical pain: a systematic literature review

Persistent postsurgical pain (PPSP) is a frequent and often disabling complication of many surgical procedures. Nerve injury-induced neuropathic pain (NeuP) has repeatedly been proposed as a major cause of PPSP. However, there is a lack of uniformity in NeuP assessment across studies, and the prevalence of NeuP may differ after various surgeries. We performed a systematic search of the PubMed, CENTRAL, and Embase databases and assessed 281 studies that investigated PPSP after 11 types of surgery. The prevalence of PPSP in each surgical group was examined. The prevalence of NeuP was determined by applying the recently published NeuP probability grading system. The prevalence of probable or definite NeuP was high in patients with persistent pain after thoracic and breast surgeries-66% and 68%, respectively. In patients with PPSP after groin hernia repair, the prevalence of NeuP was 31%, and after total hip or knee arthroplasty it was 6%. The results suggest that the prevalence of NeuP among PPSP cases differs in various types of surgery, probably depending on the likelihood of surgical iatrogenic nerve injury. Because of large methodological variability across studies, a more uniform approach is desirable in future studies for evaluating persistent postsurgical NeuP.

Transoral endoscopic surgery versus conventional thoracoscopic surgery for thoracic intervention: safety and efficacy in a canine survival model

PURPOSE

Transoral endoscopic surgery has been shown to be feasible and safe in both humans and animal models. The purpose of this study was to evaluate the safety and efficacy of transoral and conventional thoracoscopy for thoracic exploration, surgical lung biopsy, and pericardial window creation.

METHODS

The animals (n = 20) were randomly assigned to the transoral endoscopic approach group (n = 10) or conventional thoracoscopic approach group (n = 10). Transoral thoracoscopy was performed with a flexible bronchoscope via an incision over the vestibulum oris. In conventional thoracoscopy, access to the thoracic cavity was obtained through a thoracic incision. Surgical outcomes (body weight, operating time, operative complications, and time to resumption of normal diet), physiologic parameters (respiratory rate, body temperature), inflammatory parameters [white blood cell (WBC) counts and C-reactive protein (CRP)], and pulmonary parameters (arterial blood gases) were compared for both procedures.

RESULTS

The surgical lung biopsy and pericardial window creation were successfully performed in all animals except one animal in the transoral group. There was no significant difference in operating times between the groups. The increase in WBC in the transoral thoracoscopy group was significantly smaller on postoperative day 1 than in the conventional thoracoscopy group (p = 0.0029). The transoral group had an earlier return to preoperative body temperature (p = 0.041) and respiratory rate (p = 0.045) on day 7. With respect to pulmonary parameters, there was no significant difference in blood pH, pCO2, or PaCO2 between the transoral and transthoracic groups. All animals survived without complications 14 days after surgery.

CONCLUSIONS

This study demonstrated that the transoral approach was comparable to conventional thoracoscopic surgery for lung biopsy and pericardial window creation in terms of safety and efficacy.

Abnormal endogenous pain modulation is a shared characteristic of many chronic pain conditions

The intensity of acute and chronic pain depends on interactions between peripheral impulse input and CNS pain mechanisms, including facilitation and inhibition. Whereas tonic pain inhibition is a characteristic of most pain-free individuals, pain facilitation can be detected in many chronic pain patients. The capability to inhibit pain is normally distributed along a wide continuum in the general population and can be used to predict chronic pain. Accumulating evidence suggests that endogenous pain inhibition depends on activation of the prefrontal cortex, periaqueductal gray and rostral ventral medulla. Quantitative sensory test paradigms have been designed to acquire detailed information regarding each individual's endogenous pain inhibition and facilitation. Such tests include: temporal summation of pain, which is mostly used to assess facilitatory pain modulation by measuring the change in pain perception during a series of identical nociceptive stimuli; and conditioned pain modulation, which tests pain inhibition by utilizing two simultaneously applied painful stimuli (the 'pain inhibits pain' paradigm). Considerable indirect evidence seems to indicate that not only increased pain facilitation but also ineffective pain inhibition represents a predisposition for chronic pain. This view is supported by the fact that many chronic pain syndromes (e.g., fibromyalgia, temporomandibular joint disorder, irritable bowel syndrome, headache and chronic fatigue syndrome) are associated with hypersensitivity to painful stimuli and reduced endogenous pain inhibition. However, future prospective studies will be necessary to provide definitive evidence for this relationship. Such research would not only provide important information about mechanisms relevant to chronic pain but would also permit identification of individuals at high risk for future chronic pain.

Management of complicated parapneumonic effusion and empyema using different treatment modalities

To evaluate the efficacy of the 3 treatment modalities (intrapleural instillation of streptokinase, video-assisted thoracoscopic surgery, thoracotomy and decortication) in the management of complicated parapneumonic effusion and empyema, a prospective study was conducted between January 2008 and June 2010. The 69 patients (52 men and 17 women, aged 18–50 years) were divided into 3 groups: 20 patients underwent intrapleural administration of streptokinase, 25 underwent video-assisted thoracoscopic surgery, and 24 had thoracotomy and decortication. Perioperative variables, mortality, and procedure success were compared among groups. In all groups, preoperative variables were well matched for age, sex, and clinical stage according to Light’s classification. No allergic or hemorrhagic complication occurred. Operative time was significantly shorter in patients undergoing video-assisted thoracoscopic surgery. There was no intraoperative complication in the 2 surgically treated groups. Length of hospital stay and duration of chest drainage were significantly shorter after video-assisted thoracoscopic surgery. Procedure success was 50% after streptokinase, 92% after video-assisted thoracoscopic surgery, and 100% after thoracotomy and decortication. There was no perioperative mortality in any group. Video-assisted thoracoscopic surgery is a safe and effective treatment modality for complicated parapneumonic effusion and pleural empyema. Earlier intervention with video-assisted thoracoscopic surgery may produce better clinical results.

Abnormal pain modulation in patients with spatially distributed chronic pain: fibromyalgia

Many chronic pain syndromes are associated with hypersensitivity to painful stimuli and with reduced endogenous pain inhibition. These findings suggest that modulation of pain-related information may be linked to the onset or maintenance of chronic pain. The combination of heightened pain sensitivity and reduced pain inhibition seems to predispose individuals to greater risk for increased acute clinical pain. It is unknown whether such pain processing abnormalities may also place individuals at increased risk for chronic pain. Psychophysical methods can be used for the evaluation of pain sensitivity and pain inhibition. Long-term prospective studies that could yield insight into the role of heightened pain sensitivity and pain disinhibition for the development of chronic pain disorders like fibromyalgia in the general population are lacking, however.

Bullae ablation in primary spontaneous pneumothorax

BACKGROUND

The benefit of bullae ablation for the management of primary spontaneous pneumothorax (PSP) has been established. However, various modalities for bullae ablation have been reported from different centers.

OBJECTIVE

The present study aimed to assess whether endoloop ligation of bullae was as effective as staple bullectomy for preventing the recurrence of pneumothorax.

METHODS

Between January 1993 and December 2003, 226 patients (203 men and 23 women) with PSP were recorded and retrospectively reviewed. One hundred thirty (57.5%) patients were treated with endoloop ligation of bullae and the other 96 (42.5%) were treated with staple bullectomy. Mechanical abrasion was performed in all patients after bullae ablation.

RESULTS

The recurrence rate of pneumothorax was 6.2% (8 patients) in the endoloop ligation group and 17.7% (17 patients) in the staple bullectomy group (p = 0.006). The postoperative complication rate was 14.6 and 20.8% in the endoloop ligation and staple bullectomy groups, respectively (p = 0.221). The long-term chest discomfort rate after endoloop ligation and staple bullectomy was 14.6 and 13.5%, respectively (p = 0.819)

CONCLUSIONS

Endoloop ligation of bullae is as effective as mechanical staple bullectomy for the management of bullae in primary spontaneous pneumothorax.

Is video-assisted thoracic surgery lobectomy better? Quality of life considerations

Video-assisted thoracic surgery lobectomy has controversial advantages over traditional open surgical approaches. Subjective concerns such as pain, dyspnea, physical functioning, and overall satisfaction generally favor VATS but vary depending on survey timing. Independence, a major quality of life component, favors video-assisted thoracic surgery because fewer objective hospital and discharge resources are needed because pulmonary function, activity level, muscle strength, and walking capacity are better. Video-assisted thoracic surgery often hastens return to work and facilitates adjuvant chemotherapy or subsequent urgent surgical procedures. Video-assisted thoracic surgery-related quality of life benefits are amplified by advanced age (or other frailties) and reduced by advanced cancer stage or comorbid illness.

Video-assisted thoracic surgery (VATS) lobectomy: 13 years' experience

BACKGROUND

Major lung resection by video-assisted thoracic surgery (VATS) has been proven to be both safe and technically feasible, but is not routinely performed in most hospitals. The aim of this paper is to show our technique for VATS lobectomy and our experience and outcomes obtained.

METHODS

We have performed a retrospective review included all patients undergoing major pulmonary resection by VATS at the General and Thoracic Surgery Unit, Virgen Macarena University Hospital, Seville (Spain) since 1992. The clinical records of all patients were drawn from the hospital archive and data for the following variables were recorded for analysis: age, sex, clinical diagnosis, clinical status, date of surgery, type of surgery, inoperability, conversion to conventional surgery and reasons, duration of surgery and intraoperative complications, postoperative and long-term complications, postoperative stay, diagnosis, definitive status, and mortality. We also describe our surgical technique for each lobectomy.

RESULTS

A total of 237 major pulmonary resections were performed, on 203 males and 34 males, with a mean age of 61.43 years (non-small-cell bronchogenic carcinoma: 204, benign processes: 24, carcinoid tumors: 4, and lobectomy due to metastases: 5). The overall conversion rate was 14.01%. Mean duration of lobectomy was 153 min, with a median of 98 min, and mean postoperative stay was 4.2 days. The morbidity rate was 15.18%, mostly involving minor complications. Perioperative mortality was 3.7%. The actuarial 5-year survival rate was 77.7%.

CONCLUSIONS

VATS lobectomy is a viable safe procedure that meets oncological criteria for lung cancer surgery. In our experience, VATS is currently to be considered ideally indicated for certain benign processes and for T1-T2 N0 M0 bronchogenic carcinomas.

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.

Maternal separation leads to persistent reductions in pain sensitivity in female rats

We determined responses to noxious thermal stimuli, before and after morphine, and mu-opioid receptor binding in brain regions involved in nociception in maternally separated (MS), neonatally handled (H) and nonhandled (NH) female rats. Long-Evans dams were randomly assigned to either 180-minute (MS) or 15-minute (H) minute daily separations from their litters or left undisturbed (NH). At 120 days of age, paw lick latency (50 degrees C hot plate) was determined in offspring during diestrous. Rats were then given 1, 2, 5, or 10 mg/kg morphine and paw lick latency was measured. Rats were killed during diestrous and mu-opioid receptor binding was determined in discrete brain regions, using [(3)H]DAMGO autoradiography. MS rats had significantly longer (P < .05) paw lick latencies compared with H rats. The percent maximal possible effect of morphine was significantly (P < .05) lower in MS compared with H rats for the 5 mg/kg dose. Mu-Opioid receptor binding capacity was significantly greater (P < .05) in MS rats compared with H rats in the medial preoptic nucleus. In conclusion, MS and H treatments led to antipodal differences in pain sensitivity in female rats and differential mu-opioid receptor binding in the medial preoptic nucleus.

PERSPECTIVE

This article describes the persistent impact of early life adversity on pain sensitivity and the analgesic potency of morphine. Clinically, early life history may play an important role in pain symptoms and responses to opioid analgesics.

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

OBJECTIVES

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

DESIGN

Prospective nonblinded study.

SETTING

University hospital.

PARTICIPANTS

Sixty adult patients.

INTERVENTION

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSIONS

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

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.

Procedure diagnostiche invasive nelle malattie infiltrative diffuse del polmone

Le malattie polmonari che, già all’esordio clinico e/o nel loro decorso, coinvolgono più di un lobo e caratterizzate dall’accumulo od infiltrazione nel lobulo polmonare secondario di sostanze o cellule non normalmente presenti in tale sede o presenti, comunque, in quantità anomala, possono essere definite con il termine di pneumopatie infiltrative diffuse (PID) [1].

Management of postthoracotomy pain: acute and chronic

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

Video assisted thoracic surgery in the management of spontaneous pneumothorax: the current status

Over the past decade, video assisted thoracic surgery (VATS) has changed the way spontaneous pneumothorax (SP) is managed. Benefits of VATS include less postoperative pain, shorter hospital stay, and attenuated postoperative inflammatory response are evident compared with open thoracic procedures. Furthermore, the increasing acceptance by patients and referring physicians is testament to its success. Recent studies and the authors decade of experience in management of SP by VATS show that it is quick, safe, and effective, with recurrence rates generally comparable to open procedures, with some exceptions. However, selecting the correct procedure and patient, as well as knowing the limitations of the surgeons and techniques are paramount for success. Even to this day, there are considerable variations in the treatment of SP and large scale controlled studies are needed to better define timing of surgery and the role of the different procedures in the treatment and prevention of SP.