European Journal of Cardio-Thoracic Surgery Advance Access published March 18, 2014
Postoperative pain control: videothoracoscopic versus conservative mini-thoracotomic approach† Claudio Andreettia,‡*, Cecilia Mennab,‡, Mohsen Ibrahima,‡, Anna Maria Cicconea, Antonio D’Andrillia, Federico Venutac,d and Erino Angelo Rendinaa,d a b c d
Division of Thoracic Surgery, Sant’Andrea Hospital, Faculty of Medicine and Psychology, University of Rome ‘Sapienza’, Rome, Italy Division of Thoracic Surgery, ‘G. Mazzini’ Hospital of Teramo, University of L’Aquila, Teramo, Italy Division of Thoracic Surgery, Policlinico Umberto I Hospital, Faculty of Pharmacy and Medicine, University of Rome ‘Sapienza’, Rome, Italy Fondazione Eleonora Lorillard Spencer Cenci, Rome, Italy
* Corresponding author. Division of Thoracic Surgery, Sant’Andrea Hospital, Faculty of Medicine and Psychology, University of Rome ‘Sapienza’, Via di Grottarossa 1035, 00189 Rome, Italy. Tel: +39-06-33775773; fax: +39-06-33775578; e-mail: [email protected] (C. Andreetti). Received 14 September 2013; received in revised form 26 January 2014; accepted 3 February 2014
Abstract OBJECTIVES: The management of postoperative pain in thoracic surgery is an open issue. The aim of this study was to compare postoperative pain after a videothoracoscopic lobectomy versus a mini-thoracotomy approach. METHODS: Between April 2011 and January 2013 we enrolled in a prospective, non-randomized study 145 patients undergoing pulmonary lobectomy with lymphadenectomy for Stage I lung cancer. In 75 cases (Group A), surgery was performed through a videothoracoscopic approach. In 70 cases (Group B), surgery was undertaken through a conservative mini-thoracotomy. Pain was assessed by visual analogue scale and lung function by spirometry and six-minute walking test (6MWT) before surgery, at 48 h and 1 month after surgery. RESULTS: Patients were stratified by age, sex, lung function, type and duration of surgery. Length of hospital stay (median, days) was 4 for Group A and 6 for Group B (P = 0.088). The differences between mean postoperative pain values were significant at 1, 12, 24 and 48 h (6.24 vs 8.74, 5.16 vs 7.66, 4.19 vs 6.89 and 2.23 vs 5.33; P = 0.000). In Group A, mean preoperative forced expiratory volume in 1 second values were 2.65 ± 0.61, and 1.83 ± 0.65 and 2.09 ± 0.65, respectively, at 48 h and 1 month (P = 0.028); in Group B, they were 2.71 ± 0.71 preoperatively and 1.33 ± 0.52 and 1.82 ± 0.63, respectively, at 48 h and 1 month. In Group A, mean preoperative 6MWT values (m) were 426.85 ± 51.18, and 371.23 ± 55.36 and 392.07 ± 56.12, respectively, at 48 h and 1 month; in Group B, they were 421.76 ± 56.65 preoperatively and 312.03 ± 48.54 and 331.83 ± 47.99, respectively, at 48 h and 1 month (P = 0.000). CONCLUSIONS: The videothoracoscopic approach in the treatment of Stage I lung cancer reduces postoperative pain, which seems to allow a rapid functional recovery of patients. Keywords: Thoracotomy • Pain • Video-assisted thoracic surgery lobectomy
INTRODUCTION Postoperative pain control remains one of the most common problems after major lung resection. Pain is considered a major independent factor responsible for increased perioperative morbidity and mortality: in particular, in patients with preoperative compromised clinical conditions. In fact, acute pain may compromise the patient’s mobilization and the secretion’s clearance with secondary possible bronchial obstruction and parenchymal lung infection. Today, the treatment of postoperative pain after lung resection is based on association of the pharmacological therapy, including systemic use of opioids and non-steroid drugs [1], epidural analgesia [2], intercostal nerve block [3] and cryoanalgesia [4] with the † Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013. ‡ The first three authors contributed equally to this study.
minimally invasive surgery, like use of mini-thoracotomy [5], a thoracoscopic approach [6] or intercostal nerve protection with the use of muscle sparing [7]. In the literature, reduced tissue damage consequent to the use of limited surgical approaches is reported to be significantly effective in decreasing early postoperative pain [8]. Thus, the use of a minimally invasive surgery for lung resections has proved to produce more tolerable pain and allow quicker functional recovery and lower postoperative complications [9, 10]. The aim of this prospective non-randomized study was to identify the ideal minimally invasive surgical technique to reduce the postoperative pain improving surgical outcomes, comparing a videothorascopic approach versus a muscle-sparing minithoracotomic one with intercostal muscle flap harvesting and intercostal nerve block (conservative mini-thoracotomic approach). Primarily, we evaluated the differences of pain scores between the two groups. Secondly, we investigated the impact of pain reduction on functional results.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
THORACIC
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2014) 1–6 doi:10.1093/ejcts/ezu092
2
C. Andreetti et al. / European Journal of Cardio-Thoracic Surgery
MATERIALS AND METHODS Patients Between April 2011 and January 2013, we have enrolled 148 patients (99 males and 49 females) undergoing pulmonary lobectomy with lymphadenectomy for Stage I lung cancer. A written informed consent from all patients and a study approval from Sant’Andrea Hospital Ethics Committee were obtained before surgery. The inclusion criteria were: active males or females over the age of 40 years and below 86 years, patients undergoing pulmonary lobectomy, Stage I lung cancer, American Society of Anesthesiologists physical status classification risk (ASA) I and II and negative pregnancy test (for women). The exclusion criteria were: blood and coagulation diseases, severe obesity, liver diseases, rethoracotomies, immunodeficiency and ASA III and IV. In 75 cases (Group A), surgery was performed through a videothoracoscopic approach and in 70 cases (Group B) through a muscle-sparing mini-thoracotomy with intercostal muscle flap harvesting and intercostal nerve block. The mean age of patients was 62.79 ± 8.57 (range 42–83) years in Group A and 67.16 ± 14.31 (range 46–85) in Group B. All patients from both groups received identical postoperative pain regimen. A continuous intravenous analgesia was performed for both groups with infusion of tramadol (10 mg/h) and Ketorolac tromethamine (3 mg/h) starting at surgical skin incision and continuing until 48–72 h after surgery.
Afterwards, intravenous analgesia was continued with ketoralac tromethamine (10 mg for three times/ 24 h) and paracetamol (1 g for three times /24 h) until the patient’s discharge. Pain was assessed before surgery, at 1, 12, 24 and 48 h by visual analogue scale with scores ranging from 0 to 10, evaluating the efficacy of pain control achieved in the in-hospital and postoperative period. Lung function was evaluated by spirometry and six-minute walking test (6MWT) before surgery, at 48 h and 1 month after surgery. The patient discharge criteria for both groups were a mean daily drainage amount of ≤100 ml, no air leaks from the chest tube and no active clinical complications. Postoperative follow-up period was 30 days.
Surgical technique Patients from both groups were placed in lateral position with the arm abducted at 90°. Surgery was performed under general anaesthesia with selective bronchial intubation. All surgical accesses of both groups were infiltrated with 10 ml of ropivacaine (7.5 mg/ ml) before the incision. Videothoracoscopy was the surgical approach for patients of Group A (Fig. 1A–C). Videothoracoscopy was performed through an anterior approach and three surgical incisions. The first surgical incision was performed through the seventh or eighth intercostal space at the anterior axillary line for a length of 1 cm: this port was
Figure 1: Videothoracoscopic technique. (A) Right upper and lower lobectomy. (B) Middle lobe lobectomy. (C) Left upper and lower lobectomy. (D) Drainage tube at the end of surgery.
C. Andreetti et al. / European Journal of Cardio-Thoracic Surgery
3
THORACIC
dedicated to the optic, a 10-mm, 30° thoracoscope (KARL STORZ, Tuttlingen, Germany). A second incision was performed anteriorly, at the fifth intercostal space (4 cm), and used for hilar dissection and to remove the lobe at the end of the operation. The third incision (1 cm) was performed at the sixth intercostal space at the posterior axillary line. We used this access to introduce an endoscopic retractor during the hilar dissection and, after removing the lobe, for the mediastinal lymph node dissection. Endoscopic linear staplers (Endo GIA™ Reloads with Tri-Staple™ Technology and Endo GIA™ Ultra Universal staplers, COVIDIEN, Cedex, La Ciotat, France) were used for individual vessel and bronchial ligation. No rib or soft tissues retractor was used. At the end of the operation, the lobe is placed in a specimen bag for retrieval. Patients assigned to Group B received a muscle-sparing minithoracotomy through the fifth intercostal space, preserving the latissimus dorsi and the serratus anterior muscles, usually extended from the posterior to the anterior axillary line (lateral thoracotomy) for a length ranging between 9 and 10 cm (Fig. 2A). The intercostal muscle flap was easily prepared during thoracotomy, before spreading the ribs. The fifth intercostal muscle flap was harvested off from most of the superior edge of the sixth rib, using the electrocautery. Then, the flap was harvested off from the inferior edge of the fifth rib without dividing it at the extremities, just the length to insert the retractor (usually half the length of the thoracotomy). After the flap preparation, the retractor was placed against rib only, keeping the non-divided intercostal muscle flap dangling under the retractor (Fig. 2B). To protect the ribs and to avoid fractures, the chest retractor was gently opened. Immediately after the thoracotomy, patients underwent intrapleural intercostal nerve block from the fourth to the eighth space 2–3 cm from the spine, using 20 ml of ropivacaine injection, 4 ml for each space. After completion of the pulmonary resection, the intercostal muscle flap was placed back in its normal anatomical position. In both groups, a 33-Ch chest tube was positioned. In all patients who received a videothoracoscopic approach, the chest tube was positioned in the lower access (Fig. 1D). In all patients of Group B, the chest tube was positioned through the minithoracotomy (Fig. 2C).
Statistical analysis For the analysis of quantitative variables (normality of distribution verified by the Kolmogorov–Smirnov test), an unpaired t-test was used. χ 2 test was used to compare qualitative variables. An analysis of variance for repeated measures (a mixed-design ANOVA model analysis for repeated measures with factors between-subjects and within-subjects) was performed to compare pain scores and functional results [forced expiratory volume in 1 second (FEV1) and 6MWT] for the two groups, controlling preoperative variables (COPD, Chronic Obstructive Pulmonary Disease). A P-value of
Postoperative pain control: videothoracoscopic versus conservative mini-thoracotomic approach† Claudio Andreettia,‡*, Cecilia Mennab,‡, Mohsen Ibrahima,‡, Anna Maria Cicconea, Antonio D’Andrillia, Federico Venutac,d and Erino Angelo Rendinaa,d a b c d
Division of Thoracic Surgery, Sant’Andrea Hospital, Faculty of Medicine and Psychology, University of Rome ‘Sapienza’, Rome, Italy Division of Thoracic Surgery, ‘G. Mazzini’ Hospital of Teramo, University of L’Aquila, Teramo, Italy Division of Thoracic Surgery, Policlinico Umberto I Hospital, Faculty of Pharmacy and Medicine, University of Rome ‘Sapienza’, Rome, Italy Fondazione Eleonora Lorillard Spencer Cenci, Rome, Italy
* Corresponding author. Division of Thoracic Surgery, Sant’Andrea Hospital, Faculty of Medicine and Psychology, University of Rome ‘Sapienza’, Via di Grottarossa 1035, 00189 Rome, Italy. Tel: +39-06-33775773; fax: +39-06-33775578; e-mail: [email protected] (C. Andreetti). Received 14 September 2013; received in revised form 26 January 2014; accepted 3 February 2014
Abstract OBJECTIVES: The management of postoperative pain in thoracic surgery is an open issue. The aim of this study was to compare postoperative pain after a videothoracoscopic lobectomy versus a mini-thoracotomy approach. METHODS: Between April 2011 and January 2013 we enrolled in a prospective, non-randomized study 145 patients undergoing pulmonary lobectomy with lymphadenectomy for Stage I lung cancer. In 75 cases (Group A), surgery was performed through a videothoracoscopic approach. In 70 cases (Group B), surgery was undertaken through a conservative mini-thoracotomy. Pain was assessed by visual analogue scale and lung function by spirometry and six-minute walking test (6MWT) before surgery, at 48 h and 1 month after surgery. RESULTS: Patients were stratified by age, sex, lung function, type and duration of surgery. Length of hospital stay (median, days) was 4 for Group A and 6 for Group B (P = 0.088). The differences between mean postoperative pain values were significant at 1, 12, 24 and 48 h (6.24 vs 8.74, 5.16 vs 7.66, 4.19 vs 6.89 and 2.23 vs 5.33; P = 0.000). In Group A, mean preoperative forced expiratory volume in 1 second values were 2.65 ± 0.61, and 1.83 ± 0.65 and 2.09 ± 0.65, respectively, at 48 h and 1 month (P = 0.028); in Group B, they were 2.71 ± 0.71 preoperatively and 1.33 ± 0.52 and 1.82 ± 0.63, respectively, at 48 h and 1 month. In Group A, mean preoperative 6MWT values (m) were 426.85 ± 51.18, and 371.23 ± 55.36 and 392.07 ± 56.12, respectively, at 48 h and 1 month; in Group B, they were 421.76 ± 56.65 preoperatively and 312.03 ± 48.54 and 331.83 ± 47.99, respectively, at 48 h and 1 month (P = 0.000). CONCLUSIONS: The videothoracoscopic approach in the treatment of Stage I lung cancer reduces postoperative pain, which seems to allow a rapid functional recovery of patients. Keywords: Thoracotomy • Pain • Video-assisted thoracic surgery lobectomy
INTRODUCTION Postoperative pain control remains one of the most common problems after major lung resection. Pain is considered a major independent factor responsible for increased perioperative morbidity and mortality: in particular, in patients with preoperative compromised clinical conditions. In fact, acute pain may compromise the patient’s mobilization and the secretion’s clearance with secondary possible bronchial obstruction and parenchymal lung infection. Today, the treatment of postoperative pain after lung resection is based on association of the pharmacological therapy, including systemic use of opioids and non-steroid drugs [1], epidural analgesia [2], intercostal nerve block [3] and cryoanalgesia [4] with the † Presented at the 27th Annual Meeting of the European Association for CardioThoracic Surgery, Vienna, Austria, 5–9 October 2013. ‡ The first three authors contributed equally to this study.
minimally invasive surgery, like use of mini-thoracotomy [5], a thoracoscopic approach [6] or intercostal nerve protection with the use of muscle sparing [7]. In the literature, reduced tissue damage consequent to the use of limited surgical approaches is reported to be significantly effective in decreasing early postoperative pain [8]. Thus, the use of a minimally invasive surgery for lung resections has proved to produce more tolerable pain and allow quicker functional recovery and lower postoperative complications [9, 10]. The aim of this prospective non-randomized study was to identify the ideal minimally invasive surgical technique to reduce the postoperative pain improving surgical outcomes, comparing a videothorascopic approach versus a muscle-sparing minithoracotomic one with intercostal muscle flap harvesting and intercostal nerve block (conservative mini-thoracotomic approach). Primarily, we evaluated the differences of pain scores between the two groups. Secondly, we investigated the impact of pain reduction on functional results.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
THORACIC
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery (2014) 1–6 doi:10.1093/ejcts/ezu092
2
C. Andreetti et al. / European Journal of Cardio-Thoracic Surgery
MATERIALS AND METHODS Patients Between April 2011 and January 2013, we have enrolled 148 patients (99 males and 49 females) undergoing pulmonary lobectomy with lymphadenectomy for Stage I lung cancer. A written informed consent from all patients and a study approval from Sant’Andrea Hospital Ethics Committee were obtained before surgery. The inclusion criteria were: active males or females over the age of 40 years and below 86 years, patients undergoing pulmonary lobectomy, Stage I lung cancer, American Society of Anesthesiologists physical status classification risk (ASA) I and II and negative pregnancy test (for women). The exclusion criteria were: blood and coagulation diseases, severe obesity, liver diseases, rethoracotomies, immunodeficiency and ASA III and IV. In 75 cases (Group A), surgery was performed through a videothoracoscopic approach and in 70 cases (Group B) through a muscle-sparing mini-thoracotomy with intercostal muscle flap harvesting and intercostal nerve block. The mean age of patients was 62.79 ± 8.57 (range 42–83) years in Group A and 67.16 ± 14.31 (range 46–85) in Group B. All patients from both groups received identical postoperative pain regimen. A continuous intravenous analgesia was performed for both groups with infusion of tramadol (10 mg/h) and Ketorolac tromethamine (3 mg/h) starting at surgical skin incision and continuing until 48–72 h after surgery.
Afterwards, intravenous analgesia was continued with ketoralac tromethamine (10 mg for three times/ 24 h) and paracetamol (1 g for three times /24 h) until the patient’s discharge. Pain was assessed before surgery, at 1, 12, 24 and 48 h by visual analogue scale with scores ranging from 0 to 10, evaluating the efficacy of pain control achieved in the in-hospital and postoperative period. Lung function was evaluated by spirometry and six-minute walking test (6MWT) before surgery, at 48 h and 1 month after surgery. The patient discharge criteria for both groups were a mean daily drainage amount of ≤100 ml, no air leaks from the chest tube and no active clinical complications. Postoperative follow-up period was 30 days.
Surgical technique Patients from both groups were placed in lateral position with the arm abducted at 90°. Surgery was performed under general anaesthesia with selective bronchial intubation. All surgical accesses of both groups were infiltrated with 10 ml of ropivacaine (7.5 mg/ ml) before the incision. Videothoracoscopy was the surgical approach for patients of Group A (Fig. 1A–C). Videothoracoscopy was performed through an anterior approach and three surgical incisions. The first surgical incision was performed through the seventh or eighth intercostal space at the anterior axillary line for a length of 1 cm: this port was
Figure 1: Videothoracoscopic technique. (A) Right upper and lower lobectomy. (B) Middle lobe lobectomy. (C) Left upper and lower lobectomy. (D) Drainage tube at the end of surgery.
C. Andreetti et al. / European Journal of Cardio-Thoracic Surgery
3
THORACIC
dedicated to the optic, a 10-mm, 30° thoracoscope (KARL STORZ, Tuttlingen, Germany). A second incision was performed anteriorly, at the fifth intercostal space (4 cm), and used for hilar dissection and to remove the lobe at the end of the operation. The third incision (1 cm) was performed at the sixth intercostal space at the posterior axillary line. We used this access to introduce an endoscopic retractor during the hilar dissection and, after removing the lobe, for the mediastinal lymph node dissection. Endoscopic linear staplers (Endo GIA™ Reloads with Tri-Staple™ Technology and Endo GIA™ Ultra Universal staplers, COVIDIEN, Cedex, La Ciotat, France) were used for individual vessel and bronchial ligation. No rib or soft tissues retractor was used. At the end of the operation, the lobe is placed in a specimen bag for retrieval. Patients assigned to Group B received a muscle-sparing minithoracotomy through the fifth intercostal space, preserving the latissimus dorsi and the serratus anterior muscles, usually extended from the posterior to the anterior axillary line (lateral thoracotomy) for a length ranging between 9 and 10 cm (Fig. 2A). The intercostal muscle flap was easily prepared during thoracotomy, before spreading the ribs. The fifth intercostal muscle flap was harvested off from most of the superior edge of the sixth rib, using the electrocautery. Then, the flap was harvested off from the inferior edge of the fifth rib without dividing it at the extremities, just the length to insert the retractor (usually half the length of the thoracotomy). After the flap preparation, the retractor was placed against rib only, keeping the non-divided intercostal muscle flap dangling under the retractor (Fig. 2B). To protect the ribs and to avoid fractures, the chest retractor was gently opened. Immediately after the thoracotomy, patients underwent intrapleural intercostal nerve block from the fourth to the eighth space 2–3 cm from the spine, using 20 ml of ropivacaine injection, 4 ml for each space. After completion of the pulmonary resection, the intercostal muscle flap was placed back in its normal anatomical position. In both groups, a 33-Ch chest tube was positioned. In all patients who received a videothoracoscopic approach, the chest tube was positioned in the lower access (Fig. 1D). In all patients of Group B, the chest tube was positioned through the minithoracotomy (Fig. 2C).
Statistical analysis For the analysis of quantitative variables (normality of distribution verified by the Kolmogorov–Smirnov test), an unpaired t-test was used. χ 2 test was used to compare qualitative variables. An analysis of variance for repeated measures (a mixed-design ANOVA model analysis for repeated measures with factors between-subjects and within-subjects) was performed to compare pain scores and functional results [forced expiratory volume in 1 second (FEV1) and 6MWT] for the two groups, controlling preoperative variables (COPD, Chronic Obstructive Pulmonary Disease). A P-value of
