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The Cochrane Database of Systematic... Feb 2016Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Operations on structures in the chest (usually the lungs) involve cutting between the ribs (thoracotomy). Severe post-thoracotomy pain can result from pleural (lung lining) and muscular damage, costovertebral joint (ribcage) disruption and intercostal nerve (nerves that run along the ribs) damage during surgery. Poor pain relief after surgery can impede recovery and increase the risks of developing complications such as lung collapse, chest infections and blood clots due to ineffective breathing and clearing of secretions. Effective management of acute pain following thoracotomy may prevent these complications and reduce the likelihood of developing chronic pain. A multi-modal approach to analgesia is widely employed by thoracic anaesthetists using a combination of regional anaesthetic blockade and systemic analgesia, with both non-opioid and opioid medications and local anaesthesia blockade.There is some evidence that blocking the nerves as they emerge from the spinal column (paravertebral block, PVB) may be associated with a lower risk of major complications in thoracic surgery but the majority of thoracic anaesthetists still prefer to use a thoracic epidural blockade (TEB) as analgesia for their patients undergoing thoracotomy. In order to bring about a change in practice, anaesthetists need a review that evaluates the risk of all major complications associated with thoracic epidural and paravertebral block in thoracotomy.
OBJECTIVES
To compare the two regional techniques of TEB and PVB in adults undergoing elective thoracotomy with respect to:1. analgesic efficacy;2. the incidence of major complications (including mortality);3. the incidence of minor complications;4. length of hospital stay;5. cost effectiveness.
SEARCH METHODS
We searched for studies in the Cochrane Central Register of Controlled Trials (CENTRAL 2013, Issue 9); MEDLINE via Ovid (1966 to 16 October 2013); EMBASE via Ovid (1980 to 16 October 2013); CINAHL via EBSCO host (1982 to 16 October 2013); and reference lists of retrieved studies. We handsearched the Journal of Cardiothoracic Surgery and Journal of Cardiothoracic and Vascular Anesthesia (16 October 2013). We reran the search on 31st January 2015. We found one additional study which is awaiting classification and will be addressed when we update the review.
SELECTION CRITERIA
We included all randomized controlled trials (RCTs) comparing PVB with TEB in thoracotomy, including upper gastrointestinal surgery.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. Two review authors (JY and SG) independently assessed the studies for inclusion and then extracted data as eligible for inclusion in qualitative and quantitative synthesis (meta-analysis).
MAIN RESULTS
We included 14 studies with a total of 698 participants undergoing thoracotomy. There are two studies awaiting classification. The studies demonstrated high heterogeneity in insertion and use of both regional techniques, reflecting real-world differences in the anaesthesia techniques. Overall, the included studies have a moderate to high potential for bias, lacking details of randomization, group allocation concealment or arrangements to blind participants or outcome assessors. There was low to very low-quality evidence that showed no significant difference in 30-day mortality (2 studies, 125 participants. risk ratio (RR) 1.28, 95% confidence interval (CI) 0.39 to 4.23, P value = 0.68) and major complications (cardiovascular: 2 studies, 114 participants. Hypotension RR 0.30, 95% CI 0.01 to 6.62, P value = 0.45; arrhythmias RR 0.36, 95% CI 0.04 to 3.29, P value = 0.36, myocardial infarction RR 3.19, 95% CI 0.13, 76.42, P value = 0.47); respiratory: 5 studies, 280 participants. RR 0.62, 95% CI 0.26 to 1.52, P value = 0.30). There was moderate-quality evidence that showed comparable analgesic efficacy across all time points both at rest and after coughing or physiotherapy (14 studies, 698 participants). There was moderate-quality evidence that showed PVB had a better minor complication profile than TEB including hypotension (8 studies, 445 participants. RR 0.16, 95% CI 0.07 to 0.38, P value < 0.0001), nausea and vomiting (6 studies, 345 participants. RR 0.48, 95% CI 0.30 to 0.75, P value = 0.001), pruritis (5 studies, 249 participants. RR 0.29, 95% CI 0.14 to 0.59, P value = 0.0005) and urinary retention (5 studies, 258 participants. RR 0.22, 95% CI 0.11 to 0.46, P value < 0.0001). There was insufficient data in chronic pain (six or 12 months). There was no difference found in and length of hospital stay (3 studies, 124 participants). We found no studies that reported costs.
AUTHORS' CONCLUSIONS
Paravertebral blockade reduced the risks of developing minor complications compared to thoracic epidural blockade. Paravertebral blockade was as effective as thoracic epidural blockade in controlling acute pain. There was a lack of evidence in other outcomes. There was no difference in 30-day mortality, major complications, or length of hospital stay. There was insufficient data on chronic pain and costs. Results from this review should be interpreted with caution due to the heterogeneity of the included studies and the lack of reliable evidence. Future studies in this area need well-conducted, adequately-powered RCTs that focus not only on acute pain but also on major complications, chronic pain, length of stay and costs.
Topics: Acute Pain; Anesthesia, Epidural; Delirium; Humans; Hypotension; Length of Stay; Lung Diseases; Nerve Block; Pain, Postoperative; Randomized Controlled Trials as Topic; Thoracotomy
PubMed: 26897642
DOI: 10.1002/14651858.CD009121.pub2 -
Pain Physician Mar 2017Of all the postsurgical pain conditions, thoracotomy pain poses a particular therapeutic challenge in terms of its prevalence, severity, and ensuing postoperative... (Review)
Review
BACKGROUND
Of all the postsurgical pain conditions, thoracotomy pain poses a particular therapeutic challenge in terms of its prevalence, severity, and ensuing postoperative morbidity. Multiple pain generators contribute to the severity of post-thoracotomy pain, and therefore a multimodal analgesic therapy is considered to be a necessary strategy. Along with opioids, thoracic epidural analgesia, and paravertebral blocks, N-Methyl-D-Aspartate (NMDA) receptor antagonists such as ketamine have been used as adjuvants to improve analgesia.
OBJECTIVE
We reviewed the evidence for the efficacy of intravenous and epidural administration of ketamine in acute post-thoracotomy pain management, and its effectiveness in reducing chronic post-thoracotomy pain.
STUDY DESIGN
Systematic literature review and an analytic study of a data subset were performed.
METHODS
We searched PubMed, Embase, and Cochrane reviews using the key terms "ketamine," "neuropathic pain," "postoperative," and "post-thoracotomy pain syndrome." The search was limited to human trials and included all studies published before January 2015. Data from animal studies, abstracts, and letters were excluded. All studies not available in the English language were excluded. The manuscript bibliographies were reviewed for additional related articles. We included randomized controlled trials and retrospective studies, while excluding individual case reports.
RESULTS
This systematic literature search yielded 15 randomized control trials evaluating the efficacy of ketamine in the treatment of acute post-thoracotomy pain; fewer studies assessed its effect on attenuating chronic post-thoracotomy pain. The majority of reviewed studies demonstrated that ketamine has efficacy in reduction of acute pain, but the evidence is limited on the long-term benefits of ketamine to prevent post-thoracotomy pain syndrome, regardless of the route of administration. A nested analytical study found there is a statistically significant reduction in acute post-thoracotomy pain with IV or epidural ketamine. However currently, the evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy pain is insufficient due to the heterogeneity of the studies reviewed with regard to the route of administration, dosage, and outcome measures.
LIMITATIONS
The evidence for a role of ketamine as a preventative agent for chronic post-thoracotomy pain is insufficient due to the heterogeneity of the studies reviewed.
CONCLUSION
The majority of randomized controlled trials reviewed show no role for ketamine in attenuating or preventing post-thoracotomy pain syndrome at variable follow-up lengths. Therefore, additional research is warranted with consideration of risk factors and long-term follow-up for chronic post-thoracotomy pain though the evidence for benefit appears clear for acute post-thoracotomy pain.Key words: Ketamine, postoperative, thoracotomy pain, post thoracotomy pain syndrome, neuropathic pain.
Topics: Humans; Ketamine; Pain, Postoperative; Randomized Controlled Trials as Topic; Thoracotomy
PubMed: 28339431
DOI: No ID Found -
Interactive Cardiovascular and Thoracic... Jun 2022Completion lobectomy (CL) after anatomical segmentectomy in the same lobe can be complicated by severe adhesions around the hilar structures and may lead to fatal...
OBJECTIVES
Completion lobectomy (CL) after anatomical segmentectomy in the same lobe can be complicated by severe adhesions around the hilar structures and may lead to fatal bleeding and lung injury. Therefore, we aimed to investigate the perioperative outcomes of CL after anatomical segmentectomy.
METHODS
Among 461 patients who underwent anatomical segmentectomy (thoracotomy, 62 patients; thoracoscopic surgery, 399 patients) between January 2005 and December 2019, data of patients who underwent CL after segmentectomy were extracted and analysed in this study.
RESULTS
Eight patients underwent CL after segmentectomy. CL was performed via video-assisted thoracic surgery in 3 patients and thoracotomy in 5 patients. In each case, there were moderate to severe adhesions. Four patients required simultaneous resection of the pulmonary parenchyma and pulmonary artery. Thoracotomy was not required after thoracoscopic surgery in any patient. Two patients experienced complications (air leakage and arrhythmia). The median duration of hospitalization after CL was 6 (range, 5-7) days. No postoperative mortality or recurrence of lung cancer was observed. All the patients with lung cancer were alive and recurrence-free at the time of publication.
CONCLUSIONS
Although individual adhesions render surgery difficult, CL after anatomical segmentectomy shows acceptable perioperative outcomes. However, CL by video-assisted thoracoscopic surgery may be considered on a case-by-case basis depending on the initial surgery.
Topics: Humans; Lung Neoplasms; Mastectomy, Segmental; Pneumonectomy; Retrospective Studies; Thoracic Surgery, Video-Assisted; Thoracotomy
PubMed: 34962577
DOI: 10.1093/icvts/ivab323 -
Methods in Molecular Biology (Clifton,... 2016Intrathymic injection is used in several T cell-associated immunological studies to deliver cells or other substances directly into the thymus. Here, we describe the...
Intrathymic injection is used in several T cell-associated immunological studies to deliver cells or other substances directly into the thymus. Here, we describe the intrathymic injection procedure involving surgical incision of the mouse with or without a thoracotomy. Though this procedure can result in poor recovery, postsurgical complications, and distress to the animal, it is actually a simple procedure that can be carried out relatively easily and quickly with experience.
Topics: Animals; Injections; Mice; Thoracotomy; Thymus Gland
PubMed: 26294410
DOI: 10.1007/978-1-4939-2809-5_17 -
Multimedia Manual of Cardiothoracic... Mar 2021The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both...
The thoracotomy incision is essential for many thoracic surgery procedures. A number of different variations exist, and different techniques can be used, depending both on the patient and on the technical factors. The muscle-sparing technique was first described by Noirclerc et al. in 1973. [1] Initially, it was thought that preservation of the muscular structures compared with the results of a traditional posterolateral thoracotomy, in which the latissimus dorsi and sometimes the serratus anterior are often divided, would benefit long-term outcomes. However, subsequent study results have not demonstrated any difference in postoperative outcomes. The unequivocal benefit of a muscle-sparing approach is to preserve the latissimus dorsi for any future intervention, such as a procedure involving the chest wall and the intrathoracic flaps. In this video tutorial, we describe our approach to this commonly used incision, including the anatomy and the technical aspects used to provide optimal operative exposure and minimal postoperative complications while preserving the underlying musculature.
Topics: Female; Humans; Intercostal Muscles; Middle Aged; Plastic Surgery Procedures; Superficial Back Muscles; Surgical Flaps; Thoracic Wall; Thoracotomy
PubMed: 33901347
DOI: 10.1510/mmcts.2021.017 -
Jornal Brasileiro de Pneumologia :... Jan 2023
Topics: Humans; Thoracotomy; Lung Diseases; Hernia; Lung
PubMed: 36700573
DOI: 10.36416/1806-3756/e20220325 -
Minerva Anestesiologica Nov 2023Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management... (Review)
Review
Accidental or surgically induced thoracic trauma is responsible for significant pain that can impact patient outcomes. One of the main objectives of its pain management is to promote effective coughing and early mobilization to reduce atelectasis and ventilation disorders induced by pulmonary contusion. The incidence of chronic pain can affect more than 35% of patients after both thoracotomy and thoracoscopy as well as after chest trauma. As the severity of acute pain is associated with the incidence of chronic pain, early and effective pain management is very important. In this narrative review, we propose to detail systemic and regional analgesia techniques to minimize postoperative pain, while reducing transitional pain, surgical stress response and opioid side effects. We provide the reader with practical recommendations based on both literature and clinical practice experience in a referral level III thoracic trauma center.
Topics: Humans; Pain Management; Thoracic Surgery; Chronic Pain; Thoracic Surgical Procedures; Thoracoscopy; Pain, Postoperative; Thoracotomy
PubMed: 37671536
DOI: 10.23736/S0375-9393.23.17291-9 -
Pneumologie (Stuttgart, Germany) Jan 2016
Topics: Collapse Therapy; Germany; History, 20th Century; Humans; Pneumonectomy; Pulmonary Atelectasis; Thoracotomy; Tuberculosis, Pulmonary
PubMed: 26789433
DOI: 10.1055/s-0041-108309 -
Diagnostic and Interventional Imaging Oct 2016The major lung resections are the pneumonectomies and lobectomies. The sublobar resections are segmentectomies and wedge resections. These are performed either through... (Review)
Review
The major lung resections are the pneumonectomies and lobectomies. The sublobar resections are segmentectomies and wedge resections. These are performed either through open surgery through a thoracotomy or by video-assisted mini-invasive surgery for lobectomies and sublobar resections. Understanding the procedures involved allows the normal postoperative appearances to be interpreted and these normal anatomical changes to be distinguished from potential postoperative complications. Surgery results in a more or less extensive physiological adaptation of the chest cavity depending on the lung volume, which has been resected. This adaptation evolves during the initial months postoperatively. Chest radiography and computed tomography can show narrowing of the intercostal spaces, a rise of the diaphragm and shift of the mediastinum on the side concerned following major resections.
Topics: Adenocarcinoma; Adult; Aged; Female; Follow-Up Studies; Humans; Lung; Lung Neoplasms; Male; Middle Aged; Pneumonectomy; Postoperative Complications; Solitary Pulmonary Nodule; Surgery, Computer-Assisted; Surgical Instruments; Thoracic Surgery, Video-Assisted; Thoracostomy; Thoracotomy; Tomography, X-Ray Computed
PubMed: 27687830
DOI: 10.1016/j.diii.2016.08.014 -
The Journal of Thoracic and... Jan 2019
Topics: Humans; Pain; Thoracotomy
PubMed: 30528440
DOI: 10.1016/j.jtcvs.2018.09.045