The role of intercostal cryoanalgesia in post-thoracotomy analgesia.

OBJECTIVES: Patients undergoing thoracotomy were studied to compare the effects of cryoanalgesia, combined with intravenous patient-controlled analgesia (IVPCA), against IVPCA alone during the four days following surgery. METHODS: Fifty patients were randomized into two groups: an IVPCA group (n = 25) and an IVPCA-cryo group (n = 25). Subjective pain intensity was assessed on a verbal analogue scale at rest and during coughing. The intensity and the incidence of post-thoracotomy pain, numbness, epigastric distension and/or back pain, the analgesic requirements, as well as the blood gas values and respiratory function tests were evaluated up to the second postoperative (postop) month. Haemodynamic data and episodes of nausea and/or vomiting were recorded over the four postop days. RESULTS: In the cryo group there was a statistically significant improvement in postop pain scores (P = 10(-4)), reduction in consumption of morphine (P = 10(-4)) and other analgesics (P = 10(-4)), optimization (less acidosis) of the pH values of blood gases (P < 0.015 over 72 hours postop and P < 0.03 on the first and second postop months), increase in systolic blood pressure (P < 0.05 over 96 hours postop), reduction in heart rate (P < 0.05 over 96 hours postop), increase in values of FEV1 (P < 0.02) and FVC (P < 0.05) at the first and second postop months, reduction in the incidence of nausea (0.05 < P < 0.1 over 18 hours postop), numbness, epigastric distension and back pain (P < 0.05 at days 5, 6, 7, 14, 30 and 60 following surgery). CONCLUSIONS: We suggest that cryoanalgesia be considered as a simple, safe, inexpensive, long-term form of post-thoracotomy pain relief. Cryoanalgesia effectively restores FEV1 values at the second postop month.

Muscle-sparing versus posterolateral thoracotomy: a prospective study.

OBJECTIVE: Although the thoracotomy incision is guided in part by the exposure required, both cosmesis and the potential for improved recovery are important factors to be taken into account. We conducted a prospective randomized study in order to compare muscle sparing thoracotomy (MST) and standard posterolateral thoracotomy (PLT) for postoperative pain and physical function during and after hospitalization. MATERIAL AND METHOD: One hundred patients operated from June through December 2004 were recruited in this study. Fifty patients underwent MST of 6-8 cm and 50 had a PLT of more than 8 cm with division of latissimus dorsi and serratus anterior muscles. Operations performed were atypical resections and lobectomies. Pneumonectomies and operations on tumors invading the chest wall or brachial plexus were excluded. Perioperative care was standardized concerning analgetics and physiotherapy. Postoperative pain (quantitated by the visual analogue scale), preoperative and postoperative pulmonary function, shoulder strength, and range of motion were evaluated. RESULTS: There was no difference in demographics, tumor stage, and type of lung resection. Patients were also matched for the number of chest tubes, length of chest tube duration, and length of hospital stay. Pain reported during hospitalization and after hospital discharge within 1 and 2 months did not differ within the two groups (p>0.05). Shoulder function was shown to decrease less in cases of MST, but physical function was not found statistically significant in comparison of the two groups (p>0.05) within 1 month. Rehabilitation was also similar. CONCLUSION: The rates of occurrence of acute or chronic pain and morbidity were equivalent after MST and PLT. It appears that the single advantage of MST over PLT involves the preservation of chest wall musculature in case rotational muscle flaps should be needed along with a better cosmetic result.

Spontaneous hemopneumothorax: a rare but life-threatening entity.

OBJECTIVES: Spontaneous hemopneumothorax (SHP) is a rare disorder, complicating 1-12% of patients with spontaneous pneumothorax. We conducted a retrospective review in order to study this potentially life-threatening condition and compared our experience with reports in the international literature. METHODS: Between 1970 and 2000, 3489 patients were treated in our department with spontaneous pneumothorax. Seventy-one of them (2%), 63 men and 8 women, aged between 13 and 80 years, presented SHP. Patients presented dyspnea and chest pain. In the majority, chest X-ray confirmed the diagnosis of hydropneumothorax. RESULTS: All our patients were initially treated with tube thoracostomy or thoracocentesis. Conservative treatment alone was effective in 16 cases (22.5%). Among the other 55 patients (77.5%), 28 (39.4%) were operated on an emergency basis since they were in shock, while 27 (38%) were electively led to surgery for clot evacuation, resection of the bulla, ligation of the adhesion between the parietal and visceral pleura and irrigation of the pleural cavity through thoracotomy. Postoperative course was uneventful and the patients were discharged from the hospital within 7-12 days. CONCLUSIONS: (1) SHP is a rare clinical entity that can lead to potentially life-threatening complications. (2) Early thoracotomy should be considered once the diagnosis of SHP is confirmed.