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Thoracotomy and Thoracoscopy t”ROPEAN ,cJ”KNAL OF CARDIO-THORACIC SURGERY European Journal of Cardio-thoracic Surgery 12 (1997) 82-87 Thoracotomy and thoracoscopy: postoperative pulmonary function, pain and chest wall complaints’ Downloaded from https://academic.oup.com/ejcts/article/12/1/82/417840 by guest on 25 September 2021 Markus Furrer a,*, R. Rechsteiner a, V. Eigenmann a, Ch. Signer b, U. Althaus a, H.B. Ris a a Department of’ Thoracic and Cardiovascular Surgery, Inselspital, University of Bern, Bern, Switzerland b Institute of Anaesthesiology and Intensive Care, Inselspital, University of Bern, Bern, Switzerland Received 21 October 1996; received in revised form 22 January 1997; accepted 11 March 1997 Abstract Objective: Two different surgical accesses combined with standard pain management procedures are compared regarding early and intermediate pulmonary function and pain relief. Methods: In a prospective study, 15 consecutive patients undergoing video-thoracoscopy for pulmonary wedge resection (group 1) were matched to 15 patients undergoing standard postero-lateral thoracotomy for lobectomy (group 2) according to age, gender and preoperative pulmonary function. Postoperative pain control consisted of patient controlled analgesia in group 1 and epidural analgesia in group 2. Pain intensity was scored from O-4. The predicted postoperative pulmonary function (FVC and FEV 1) after lobectomies was calculated from the preoperative value according to the extent of resection. A clinical measurement was obtained after a mean follow-up time of 4.2 months. Results: The ratios of postoperative measured to predicted values of FVC and FEW for group 1 compared with group 2 were 0.64 f 0.15 and 0.65 f 0.14 compared with 0.60 + 0.19 and 0.59 f 0.13, resp. (both n.s.) at the first day postoperative; 0.92 f 0.18 and 0.95 i 0.17 compared with 0.76 f 0.20 (P < 0.05) and 0.83 f 0.23 (n.s.), resp. at hospital discharge; 0.98 _+ 0.10 and 0.94 f 0.14 compared with 1.01 k 0.17 (n.s.) and 1.10 f 0.17 (P < 0.0.5), resp. at follow-up. Pain intensity score one day after surgery ranged from 0.4 (resting position) to 1.6 (coughing) for group 1, and from 0.3 to 1.2 for group 2. Thirty-six percent of the thoracoscopy patients and 33% of the thoracotomy group complained of persistent pain or discomfort on the site of the operation after 3- 18 months. Conclusion: Post-thoracotomy pain can be effectively controlled with epidural analgesia and pain intensity is no higher than in patients after thoracoscopy who are managed with patient controlled analgesia. FVC is slightly more decreased after thoracotomy during the early postoperative period. FVC and FEV 1 approach the predicted values after four months in both groups. The rate of persistent pain is similar after thoracoscopy and thoracotomy. 0 1997 Elsevier Science B.V. Keywords: VATS; Postoperative pain; Pulmonary function; Prevalence of chronic pain 1. Introduction are major goals during the early postoperative period following major thoracic surgery. Thoracotomy is considered to be among the most During the past decade, thoracic surgeons have pur- painful operative procedures [9,15,16]. Perioperative sued innovative techniques to minimize the surgical pain control and maintenance of pulmonary function insult. Modifications of conventional techniques such as a muscle sparing postero-lateral thoracotomy have been shown to be associated with a marked reduction in * Corresponding author. Present address: Thoracic and Vascular postoperative pain [6]. Video-assisted-thoracic-surgical Surgery, Kantonsspital Chur, CH-7000 Chur, Switzerland. Tel: + 41 (VATS) techniques seem not only to improve patient 81 2566207; fax: f41 81 2566279. ’ Prcscnted at the 10th Annual Meeting of the European Associa- comfort, but also to reduce early postoperative depres- tion for Cardio-thoracic Surgery, Prague, Czech Republic, 6-9 Octo- sion of pulmonary function [20]. Most of the reports on ber 1996. VATS techniques, however, have only adressed feasibil- lOlO-7940/97/$17.00 0 1997 Elsevier Science B.V. All rights reserved. P11s1010-7940(97)00105-x hf. Furrer et al. /European Journal of Cardio-thoracic Surgery 12 (1997) 82-87 83 ity and technical outcome [1,2,8,10,11,14,17,18]. The ing procedure: Two patients from group 1 younger impact on functional outcome still needs to be clearly than 20 years of age were excluded in the consecutive defined by randomized studies comparing these new series of 32 patients for a correct matching of the two minimally invasive techniques to accepted conventional groups). procedures. The second approach to minimizing postoperative 2.4. Endpoints of the study pain focuses on techniques which improve pain control such as regional and epidural anaesthesia (EDA, by opioids, local anaesthesia, or both), or patient controlled 2.4.1. Pulmonary function test In all patients the same method of bedside spirometry intravenous analgesia (PCA, by opioids). While patients was used (Microlab 33, Micro Medical Ltd. Rochester, may benefit from EDA after conventional thoracotomy, regional techniques seem unnecessary in patients under- Kent ME12 AZ England). Forced vital capacity (FVC) Downloaded from https://academic.oup.com/ejcts/article/12/1/82/417840 by guest on 25 September 2021 and forced expiratory volume in 1 s (FEV 1) were going simple thoracoscopic procedures [7]. measured the day before surgery, the day after surgery, In cancer patients performing major pulmonary resec- at hospital discharge and after an intermediate follow-up tions through a thoracotomy is still considered the gold period (mean follow-up time 4.2 months). The best values standard for such proceclures, as VATS techniques might after three attempts were recorded. compromize oncologic principles in thoracic surgery [3,5]. The main effort, therefore, should be to optimize For lobectomy patients postoperative predicted opti- mal pulmonary function was calculated according to the perioperative pain management in those patients who recommendations of Loddenkemper [13]. In the case of still have to undergo thoracotomy. Nevertheless, com- small pulmonary wedge resections postoperative pre- paring the functional postoperative outcomes after dicted optimal values were approximated as being iden- VATS and conventional thoracotomy procedures as well tical to preoperative values. as different pain control techniques has important clini- cal relevances. The degree of pulmonary function depression was In accordance with our routine clinical practice we expressed as a ratio of measured postoperative to pre- dicted values. therefore compared in a prospective study two different standard procedures for pulmonary resections and their respective and perioperative pain control regimens 2.4.2. Pain intensity scoring (Video-thoracoscopic and PCA vs. postero-lateral thora- Pain was evaluated at rest and during coughing at the cotomy and EDA). The study compared differences in same time as pulmonary function was measured. Postop- early and intermediate postoperative pulmonary func- erative pain intensity was ranked by a nurse using a visual tion, pain control and prevalence of chest wall com- analog pain scale which ranged from 0 to 4. plaints. 2.4.3. Intermediate follow-up All patients were well managed clinically in terms of 2. Methods and material persistent postoperative pain and shoulder girdle func- tion. 2.1. Study design 2.5. Patients In a prospective study 15 consecutive patients under- going video-thoracoscopy for a pulmonary wedge resec- tion (group 1) were matched to 15 patients undergoing 2.5.1. Age, gender and preoperative pulmonary function a standard postero-lateral thoracotomy for a lobectomy The two groups did not differ in age (55.7 f 18.3 vs. (group 2) according to age, gender and preoperative 60.7 + 9.2 years), gender (9 male and 6 female vs. 11 male pulmonary function. and 4 female) and preoperative pulmonary function (FVC3.56f1.04vs.3.41f0.551andFEV12.71+0.96 2.2. Inclusion criteria vs. 2.25 f. 0.55 1). For group 1 (video-thoracoscopies): Peripheral pul- 2.5.2. Postoperative diagnosis monary wedge resections and for group 2 (postero-lateral In group 1, six patients had benign nodules (four thoracotomy): Lobectomy for stage I or II lung cancer. hamartomas, two granulomas), five had malignant pulmonary nodules (two from metastatic lung cancers, 2.3. Exclusion criteria three from metastatic disease or malignant lymphoma), and one patient each suffered from pulmonary infarc- Preoperative chest lube, retained pulmonary secre- tion, pneumonia, apical bullous emphysema and histio- tions, atelectasis or pneumonia, age < 20 years (match- cytosis. 84 M. Furrer et al. /European Journal of Cardio-thoracic Surgery 12 (1997) 82-87 In group 2, 14 patients had stage I or II lung cancers. Additionally in all patients of both groups, 1 g of In one patient with preoperative suspected lung cancer Paracetamol (PanadoP) was administered every 8 h. histological analyses was consistent with a hamartoma. 2.6. Surgical techniques 2.8. Statistical analyses All interventions were performed under general Data of the two groups were compared using un- anaesthesia and single-lung ventilation (double-lumen paired t-test analyses. tube) with the patient in the lateral decubitus position. Two Charriere 28 G chest tubes were inserted at the end of the surgery. 3. Results In group l-patients three trocar sleeves ranging in Downloaded from https://academic.oup.com/ejcts/article/12/1/82/417840 by guest on 25 September 2021 diameter from seven to 11 mm were placed in the seventh and fourth intercostal spaces thus forming a 3.1. Pulmonary function test triangle. A straight, 0 degree 7 mm telescope (Richard Wolf GmbH, Knittlingen, Germany) was used. Pul- Mean FVC and FEV 1 depressions measured the first monary resection was performed using a multiple fire postoperative day ranged from 59% to 64% of the Endo-GIA-30 mm stapler (Autosuture Company Divi- predicted postoperative values with no significant dif- sion, United States Surgical Corporation, Norwalk, ferences between the two groups.
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