Harmonic technology versus neodymium-doped yttrium aluminium garnet laser and electrocautery for lung metastasectomy: an experimental study.

OBJECTIVES: We compared the efficacy of non-anatomical lung resections with that of three other techniques: monopolar electrocautery; neodymium-doped yttrium aluminium garnet laser and harmonic technology. We hypothesized that the thermal damage with harmonic technology could be reduced because of the lower temperatures generated by harmonic technology compared with that of other devices. METHODS: Initial studies were performed in 13 isolated pig lungs for each group. A 1.5-cm capsule was inserted within the lung to mimic a tumour and a total of 25 non-anatomical resections were performed with each device. The damage of the resected lung surface and of the tumour border were evaluated according to the colour (ranging from 0-pink colour to 4-black colour), histological (ranging from Score 0-no changes to Score 3-presence of necrotic tissue) and radiological (ranging from Score 0-isointense T2 signal at magnetic resonance imaging to Score 3-hyperintense T2 signal) criteria. A total of seven non-anatomical resections with harmonic technology were also performed in two live pigs to assess if ex vivo results could be reproducible in live pigs with particular attention to haemostatic and air-tightness properties. RESULTS: In the ex vivo lung, there was a statistical significant difference between depth of thermal damage (P < 0.0001) in electrocautery (1.3 [1.2-1.4]), laser (0.9 [0.6-0.9]) and harmonic (0.4 [0.3-0.5]) groups. Electrocautery had a higher depth of thermal damage compared with that of the laser (P = 0.01) and harmonic groups (P = 0.0005). The harmonic group had a less depth of thermal damage than that of the laser group (P = 0.01). Also, histological damages of tumour borders (P < 0.001) and resected lung surface (P < 0.001), radiological damage of tumour borders (P < 0.001) and resected lung surface (P < 0.001) and colour changes (P < 0.001) were statistically different between three study groups. Resections of in vivo pig lungs showed no bleeding; 2 of 7 cases of low air leaks were found; however, they ceased by sealing lung parenchyma with harmonic technology. CONCLUSIONS: Our experimental data support the resections performed with the use of harmonic technology. The lack of severe tissue alterations could favour healing of parenchyma, assure air tightness and preserve functional lung parenchyma. However, randomized controlled studies are needed in an in vivo model to corroborate our findings.

Efficacy of wound analgesia for controlling post-thoracotomy pain: a randomized double-blind study†.

OBJECTIVES: Continuous wound infusion of local anaesthetics has been successfully applied for postoperative pain control in several procedures but, surprisingly, it is underused in thoracic surgery. We aimed to investigate the effects of wound analgesia associated with systemic patient-controlled analgesia in patients undergoing lung cancer resection with muscle-sparing thoracotomy. METHODS: Sixty consecutive patients undergoing lung cancer resection via standard muscle-sparing thoracotomy were randomized into two groups (wound analgesia and placebo groups). Bupivacaine in the wound group and free-saline solution in the placebo group were injected using a multiholed catheter connected to an elastomeric pump inserted at the end of operation between the pericostal sutures and the serratus muscle and removed 48 h after. The inter-group differences were assessed by the following criteria: (i) level of cytokines [IL-6, IL-10 and tumour necrosis factor-alpha (TNF-alpha)]; (ii) pain on a visual analogue scale at rest and after coughing; (iii) recovery of respiratory functions (flow expiratory volume in 1 s % and forced vital capacity %) and (iv) narcotic medication consumption at different time points of the postoperative course. RESULTS: Five out of a total of 60 patients were excluded from the final analysis. Thus, the wound and placebo groups comprised 27 and 28 patients, respectively. The wound group compared with the placebo group had a significant decrease of IL-6 (P < 0.001), IL-10 (P < 0.001) and TNF-alpha (P < 0.001) blood concentration levels, pain scores at rest (P < 0.001) and after coughing (P = 0.01), and a reduction of additional morphine intake (P = 0.03) and Ketorolac (P = 0.01) during the entire postoperative course. The recovery of the flow expiratory volume in one second % (P = 0.01) and the forced vital capacity % (P = 0.02) was also better in the wound than in the placebo group. CONCLUSIONS: Our data prove that wound analgesia is an effective, easy and safe procedure. It significantly reduces systemic inflammatory markers, pain scores and opioid intake; and accelerates the recovery of respiratory function. Catheter placement does not require particular manoeuvres by the surgeon nor does the elastomeric pump need any adjustment or care by physicians or nurses.

A simple technique to control placement of Dumon stent in subglottic tracheal stenosis.

Airway stenting is the chosen treatment for patients affected by subglottic tracheal stenosis and unfit for surgery. Among the different types of prostheses, the Dumon stent is a valid option especially in patients without tracheotomy. Insertion is usually achieved by pushing the stent off from a loader using a prosthesis pusher. If the stent is expelled below the stenosis, rigid forceps grasping the proximal end of the stent retract it above the stenosis. However, in difficult cases such as rigid stenosis with a luminal diameter smaller than the profile of the stent, such a manoeuvre may be difficult in non-expert hands. Thus, we proposed a simple and safe technique to facilitate the placement of a Dumon stent. We passed a long thread from outside to the inside of the stent. After the dilatation of the stenosis, the stent was pushed and, if needed, easily retracted with the thread into the proper position to ensure airway patency and to avoid migration. In addition, our procedure could be useful also to rapidly remove the stent if its size turned out to be inaccurate for the stenosis. With such a simple method we successfully treated 7 consecutive patients affected by complex subglottic stenosis and unfit for surgery.