Functional recovery after discharge in enhanced recovery video-assisted thoracoscopic lobectomy: a pilot prospective cohort study

Comparison of Thoracoscopy-Guided Thoracic Paravertebral Block and Ultrasound-Guided Thoracic Paravertebral Block in Postoperative Analgesia of Thoracoscopic Lung Cancer Radical Surgery: A Randomized Controlled Trial

INTRODUCTION

Ultrasound-guided thoracic paravertebral block (UTPB) is widely used for postoperative analgesia in thoracic surgery. However, it has many disadvantages. Thoracoscopy-guided thoracic paravertebral block (TTPB) is a new technique for thoracic paravertebral block (TPB). In this study, we compared the use of TTPB and UTPB for pain management after thoracoscopic radical surgery for lung cancer.

METHODS

In total, 80 patients were randomly divided 1:1 into the UTPB group and the TTPB group. The surgical time of TPB, the success rate of the first puncture, block segment range, visual analog scale (VAS) scores at 2, 6, 12, 24, and 48 h post operation, and the incidence of postoperative adverse reactions were compared between the two groups.

RESULTS

The surgical time of TPB was significantly shorter in the TTPB group than in the UTPB group (2.2 ± 0.3 vs. 5.7 ± 1.7 min, t = - 12.411, P < 0.001). The success rate of the first puncture and the sensory block segment were significantly higher in the TTPB group than in the UTPB group (100% vs. 76.9%, χ2 = 8.309, P < 0.001; 6.5 ± 1.2 vs. 5.1 ± 1.3 levels, t = - 5.306, P < 0.001, respectively). The VAS scores were significantly higher during rest and coughing at 48 h post operation than at 2, 6, 12, and 24 h post operation in the TTPB group. The VAS scores were significantly lower during rest and coughing at 12 and 24 h post operation in the TTPB group than in the UTPB group (rest: 2.5 ± 0.4 vs. 3.4 ± 0.6, t = 7.325, P < 0.001; 2.5 ± 0.5 vs. 3.5 ± 0.6, t = 7.885, P < 0.001; coughing: 3.4 ± 0.6 vs. 4.2 ± 0.7, t = 5.057, P < 0.001; 3.4 ± 0.6 vs. 4.2 ± 0.8, t = 4.625, P < 0.001, respectively). No significant difference was observed in terms of postoperative adverse reactions between the two groups.

CONCLUSIONS

Compared with UTPB, TTPB shows advantages, such as simpler and more convenient surgery, shorter surgical time, a higher success rate of the first puncture, wider block segments, and superior analgesic effect. TTPB can effectively reduce postoperative pain due to thoracoscopic lung cancer radical surgery.

TRIAL REGISTRATION

https://www.chictr.org.cn , identifier ChiCTR2300072005, prospectively registered on 31/05/2023.

Enhanced recovery after surgery program focusing on chest tube management improves surgical recovery after video-assisted thoracoscopic surgery

OBJECTIVE

Chest drainage is a standard procedure in thoracoscopic surgery for lung cancer. However, chest tube placement may deteriorate the ventilation capacity and increase difficulty of postoperative management of patients. The study investigated on the effects of enhanced recovery after surgery (ERAS) program focusing on chest tube management on surgical recovery of lung cancer patients.

METHODS

The study population consisted of 60 patients undergoing video-assisted thoracoscopic surgery (VATS) after implementation of ERAS program and another group of 60 patients undergoing VATS before implementation of ERAS program.

RESULTS

The mean time of first food intake was 12.9 h required for the ERAS group, which was significantly shorter than 18.4 h required for the control group (p < 0.0001). The mean time of out-of-bed activity was 14.2 h taken for the ERAS group, which was notably shorter than 22.8 h taken for the control group (p < 0.0001). The duration of chest tube placement was 68.6 h in the ERAS group, which was remarkably shorter than 92.8 h in the control group (p < 0.0001). The rate overall postoperative complications were notably lower in the ERAS group than in the control group (p = 0.018). The visual analogue score (VAS) scores on the second postoperative day exhibited significant differences between the ERAS group and the control group (p = 0.017). The patients in the ERAS group had a shorter hospitalization stay than those in the control group (p < 0.0001).

CONCLUSION

The study suggests the ERAS program focusing on chest tube management could improve surgical recovery, remove patient chest tube earlier, and relieve patient pain after VATS.

Exploring the need for reconsideration of trial design in perioperative outcomes research: a narrative review

"Enhanced recovery after surgery" is a multimodal effort to control perioperative pathophysiology and improve outcome. However, despite advances in perioperative care, postoperative complications and the need for hospitalisation and prolonged recovery continue to be challenging. This is further complicated by procedure-specific and patient-associated risk factors, given the increase in the number of elderly and frail patients with multiple comorbidities undergoing surgery. This paper is a critical assessment of current methodology for trials in perioperative medicine. We make a plea to reconsider the design of future interventional trials to improve surgical outcome, based upon studies of potentially effective interventions, but often without improvements in recovery. The complexity of perioperative pathophysiology necessitates a procedure- and patient-specific approach whenever outcome is assessed or interventions are planned. With improved understanding of perioperative pathophysiology, the way to improve outcomes looks promising, provided that knowledge and established enhanced recovery programmes are integrated in trial design.

Funding

None.

Objectively measured activity is not associated with average pain intensity 1 week after surgery: A cross-sectional study

BACKGROUND

Measures of physical activity and pain-related patient-reported outcomes are important components of patient recovery after surgery. However, little is known about their association in the early post-operative period. This study aims to increase this knowledge. Our primary objective was to determine the association between average pain intensity and activity (in steps) 1 week after surgery. Secondary objectives were the association of activity with other patient-reported outcomes, age, sex, comorbidities and body mass index.

METHODS

Data were obtained from the PROMPT sub-project of IMI-PainCare. Patients after breast and endometriosis-related surgery, sternotomy and total knee arthroplasty completed pain-related outcomes questionnaires and wore an ActiGraph activity-tracking device. We correlated steps with average pain intensity on post-operative days 6 and 7. Secondary analyses were done using correlations and t-tests.

RESULTS

In 284 cases, there was no statistically significant correlation between steps and average pain intensity. In addition, none of the 28 secondary analyses showed a statistically significant result.

CONCLUSIONS

Pain-related patient-reported outcome measures and physical activity are separate entities. Both should be measured after surgery to assess patient recovery and to identify treatment deficiencies.

SIGNIFICANCE STATEMENT

Measuring recovery is a multi-dimensional challenge. After surgery, clinicians need to be aware that neither pain intensity nor activity levels tell the whole story. Each can hint to problems and treatment requirements.

Effect of propofol and sevoflurane on postoperative fatigue after laparoscopic hysterectomy

BACKGROUND

Postoperative fatigue syndrome (POFS) is an important factor in postoperative recovery. However, the effect of anesthetic drugs on postoperative fatigue in female patients has been rarely studied. This study compared the effects of maintaining general anesthesia with propofol or sevoflurane on the incidence of POFS in patients undergoing laparoscopic hysterectomy.

METHODS

This prospective, single-blind, randomized controlled trial enrolled patients scheduled for laparoscopic hysterectomy. Eligible patients were randomized into the propofol and sevoflurane groups. The primary outcome was the incidence of POFS within 30 Days, defined by a simplified identity consequence fatigue scale (ICFS-10) scores≥24 or Visual Analogue Scale (VAS) scores of fatigues>6. Secondary outcomes were perioperative grip strength, early ambulation and anal exhaust after surgery, and inpatient days.

RESULTS

32 participants were assigned to the propofol group (P) and 33 to the sevoflurane group (S). Incidence of POFS on postoperative D1 was P (8/32) vs. S (10/33) (p = 0.66, 95% confidence interval [CI]: 16.4-27.00); D3 P (2/32) vs. S (5/33) (p = 0.45,95% CI:5.96-23.76). POFS were not found on postoperative D5 and D30. There were no differences in perioperative grip strength, early ambulation and anal exhaust after surgery, and inpatient days between the two groups.

CONCLUSIONS

POFS after scheduled laparoscopic hysterectomy was unaffected by anesthesia with propofol vs. sevoflurane. The incidence of POFS was highest on the first postoperative day, at 27.7%, and declined progressively over the postoperative 30 days. Trial registration Chinese Clinical Trial Registry (No. ChiCTR 2,000,033,861), registered on 14/06/2020).

The Year in Thoracic Anesthesia: Selected Highlights from 2022

This article reviews research highlights in the field of thoracic anesthesia. The highlights of this year included new developments in the preoperative assessment and prehabilitation of patients requiring thoracic surgery, updates on the use of devices for one-lung ventilation (OLV) in adults and children, updates on the anesthetic and postoperative management of these patients, including protective OLV ventilation, the use of opioid-sparing techniques and regional anesthesia, and outcomes using enhanced recovery after surgery, as well as the use of expanding indications for extracorporeal membrane oxygenation, specialized anesthetic techniques for airway surgery, and nonintubated video-assisted thoracic surgery.

Days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in the era of enhanced recovery

BACKGROUND

Days alive and out of hospital is proposed as a valid and patient-centred quality measure for perioperative care. However, no procedure-specific data exist after pulmonary wedge resection. The aim of this study was to assess the first 90 days alive and out of hospital after video-assisted thoracoscopic surgery wedge resection in an optimized enhanced recovery programme.

METHODS

A retrospective analysis of prospectively collected data of consecutive patients undergoing enhanced recovery thoracoscopic wedge resections from January 2021 to June 2022 in a high-volume centre was carried out. All factors leading to hospitalization, readmission, and death were evaluated individually. A logistic regression model was used to evaluate predictors. Additionally, a sensitivity analysis was performed.

RESULTS

A total of 433 patients were included (21.7% (n = 94) with non-small cell lung cancer, 47.6% (n = 206) with metastasis, 26.8% (n = 116) with benign nodules, and 3.9% (n = 17) with other lung cancers). The median duration of hospital stay was 1 day. The median of postoperative 30 and 90 days alive and out of hospital was 28 and 88 days respectively. Air leak (112 patients) and pain (96 patients) were the most frequent reasons for reduced days alive and out of hospital from postoperative day 1 to 30, whereas treatment of the original cancer or metastasis (36 patients) was the most frequent reason for reduced days alive and out of hospital from postoperative day 31 to 90. Male sex, reduced lung function, longer dimension of resection margin, pleural adhesions, and non-small cell lung cancer were independent risks, confirmed by a sensitivity analysis.

CONCLUSION

Days alive and out of hospital within 90 days after enhanced recovery thoracoscopic wedge resection was only reduced by a median of 2 days, mainly due to air leak and pain.

Early and Late Readmission after Enhanced Recovery Thoracoscopic Lobectomy

OBJECTIVES

The purpose of this study was to describe the incidence and reasons for early (0-30 days) and late (31-90 days) readmission after enhanced recovery video-assisted thoracoscopic surgery lobectomy.

METHODS

We performed a retrospective analysis of prospectively collected consecutive VATS lobectomy data in an institutional database from January 2019 until December 2020. All reasons for readmission with complete follow-up were individually evaluated. Univariable and multivariable analyses were used to assess predictors.

RESULTS

In total 508 patients were included and median length of stay after surgery was 3 days. Early and late readmission were 77 (15%) and 54 (11%), respectively. Multiple readmissions during postoperative 0-90 days were 33 (7%). Pneumonia (19.8%) and pneumothorax (18.3%) were the dominant reasons for early readmission, and side effects to adjuvant chemotherapy (22.0%) for late readmission. In multivariable analyses, current smoking (P = 0.001), alcohol abuse (P = 0.024) and chronic obstructive pulmonary disease (P = 0.019) were predictors for early readmission, while (Clavien-Dindo I-II grade gastrointestinal complicationspredicted late readmission (P = 0.006) and multiple readmissions (P = 0.007). Early discharge (< 3 days) was not a predictor for readmission. Early readmission does not increase late readmission.

CONCLUSIONS

Early and late readmission are frequent despite of following enhanced recovery programs after video-assisted thoracoscopic lobectomy. Pulmonary complications and adjuvant chemotherapy are the most predominant reasons for early and late readmission.