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Хронические последствия после торакоскопических операций по поводу доброкачественных заболеваний
Eur J Cardiothorac Surg 2000;17:687
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Up to 40% of patients undergoing lateral thoracotomy may experience chronic postthoracotomy pain for up to several years after their thoracic surgical procedure .
In two studies [6,7] comparing the rate of acute and chronic pain after thoracotomy and VATS resections, no significant difference could be found in persistent long-term pain.
There have been a few reports regarding the prevalence of chronic sequels in the literature after thoracoscopic procedures for benign diseases. Worsening pain, following an interval of initial control, often reflects tumour recurrence in malign disease .
The mechanism of pain after thoracoscopic procedures is explained by excessive torquing of the instruments (trocars) in the intercostal space, resulting in potential rib fracture or direct injury to the neurovascular bundle, as well as direct damage to the intercostal nerve by electrosurgical access or blunt dissection to access the pleural space .
We were not able to compare a series of patients treated for benign primary disease, either by open thoracotomy or thoracoscopy, due to the small number of patients operated through an open thoracotomy.
In 23 cases, the procedure had to be converted to an open operation. The indication for conversion was empyema in 12 cases, when complete expansion of the lung could not be achieved, in three cases, the lesion could not be identified, and in another three, a lobectomy with thoracotomy was indicated. In one case, a postoperative bleeding indicated reoperation through a thoracotomy, two persistent pneumothoraces indicated thoracotomy, and in another two cases, single-lung ventilation could not be established.
In the remaining 161 patients, the procedure could be performed successfully by thoracoscopy without any auxiliary minithoracotomy.
In cases of diagnostic intervention of the pleural space or the mediastinum, one 10-mm and one or two 5-mm trocars were inserted, and in cases of parenchyma resection, an additional 12-mm trocar (for the Endo GIATM Stapler, USSC) was inserted into the pleural space for thoracoscopy. Due to the narrow intercostal space, paravertebrally trocars larger than 5 mm were avoided in this area.
After removal of the trocars, one or two drains (24 and 28 French ) were placed in the pleural space through trocar incisions.
Of the 161 patients who were not converted to an open procedure, 12 were already deceased and five could not be reached either by phone or mail.
Among the 144 patients who were eligible for final evaluation, 97 were male and 47 were female.
The mean age was 47 years (7㫮 years), and the mean follow-up was 34 months (2㫠 months).
A variety of thoracoscopic procedures for different indications were performed: pneumothorax, 42 (29.2%); empyema, 38 (26.4%); interstitial lung disease (lung biopsy), 16 (11.1%); unclear pleural effusion, ten (6.9%); emphysema, seven (4.8%); harmatoma, six (4.2%); tuberculoma, five (3.5%); others, 20 (13.9%). In all cases of pneumothorax, a parietal pleurodesis, but not pleurectomy, was performed.
The indication for the procedure was primarily diagnostic in 40 (27.7%) cases and therapeutic in 104 (72.3%) cases.
Chronic sequels were defined as either pain, numbness or disaesthesia, or a combination of the three, in the area of the trocar sites, persisting for longer than 2 months after the procedure.
The following factors were checked for significance for chronic sequels: age, sex, number of drains used, use of stapling devices and length of drainage. The use of stapling devices was additionally checked for significance for chronic pain, numbness and disaesthesia.
The following parameters were investigated using a questionnaire sent by mail or telephone: sequels (generally), and if yes, then pain, disaesthesia, numbness; regular use of painkillers; if bothered in the daily life activity by the sequels; and ability to work.
2.1. Statistical methods
Eighteen (39.1%=12.5% of all patients reached) patients suffer from their complaints only at exercise, and 26 (56.5%=18.1% of all patients reached) suffer even while at rest. In 41 (89.1%=28.5% of all patients reached) patients, the sequels are weather dependent. From the group of patients with chronic pain, 24 (82.8%) patients take painkillers on a regular basis, 19 (65.5%) are bothered by the pain in their daily life activity, and nine (31.0%) are unable to work.
Sequels were present in 23% of patients who were operated on for diagnostic reasons only, and in 31% with the therapeutic operation. Complications were present in 18 (12,5%) patients, with wound infection in eight (5.6%) patients, prolonged air leakage (>7 days) in four (2.8%), prolonged fever (>7 days) in three (2.1%), persistent pneumothorax in two (1.4%), and respiratory insufficiency in one (0.7%) patient.
Drain removal was at a mean of 2.4 days (0㪨 days), and the patients were discharged from hospital at a mean of 7.3 days (1㪸 days).
The use of Staplers (P>0.05; odds ratio=0.4641; C.I.=0.206ם.023), as well as the number of drains (1 vs. 2;P>0.05; C.I.=0.0001ל.0001) used, were statistically significant for a combination of chronic sequels, but not for pain, numbness or disaesthesia alone. All other investigated factors did not reach statistical significance (Table 1).
Table 1. P values for the variables investigateda
In light of the relatively young age of our patients, with a mean age of 46 years and a mean life expectancy of more than 30 years, we should consider a re-evaluation of the indication for the operation, especially in benign diseases or in cases of a diagnostic reason only. The VATS approach is not likely to impact on the prevalence of long-term postthoracotomy sequels, and we still have to tell our patients that minimally invasive surgery does not mean no risk or no side-effects.
Dr Hutter: That is correct.
Dr Rice: The questionnaire was only done at one point?
Dr Hutter: Thats right. That was at a mean of 32 months after the operation.
Dr Rice: I think your paper is valid, one, because it is one group of patients with only benign disease, but then again, I think your analysis can only be carried out at one time. But I think it is very important, because people with benign disease truly deal with their pain differently than those patients with malignant, and also, people who undergo diagnostic procedures arent quite as happy as those who undergo therapeutic procedures with their pain. So I think these studies are important, but have flaws in their analysis.
Dr Hutter: First, we looked at the time difference since the operation if there was any difference, but we didnt find any significant difference, and secondly, either diagnostic or therapeutic, there was no statistically significant difference in sequels.
Dr Rice: But you didnt do it just for the one time period. The statistics, to go retrospectively and then divide them into groups, that is pretty complex.
Dr Hutter: Thats right.
Dr T. Molnar (Pecs, Hungary): Regarding the validity of these results, I would add that we cannot ignore that the patients have memory, so they can remember earlier pains, Im afraid.
Dr K. Naunheim (St. Louis, MO, USA): I was wondering if you had analyzed this over time in terms of the chronological experience. I think we all know that as we have improved at VATS, we have improved at positioning the ports, so we have to torque a little less. In addition, the size of the instrumentation has decreased, and even our utilization of chest tubes has changed. We no longer use, for most patients, 32 French chest tubes. We will use 24 or 20 French chest tubes.
All those things can have a significant effect on the incidence and the severity of postoperative pain, and many of those things have changed, over a period of time. For that reason, I think that perhaps a direct comparison of the first half of your experience to the second half could be a significant predictor for the sequelae of pain. I wonder if you have looked at that?
Dr Hutter: Well, I think I mentioned before that we investigated this, and in the early period, there was no difference to the last period.
Dr J.W. Rubin (Augusta, GA, USA): My colleagues in the pain clinics tell me that a semi-quantitative scale for measuring pain is still valid. I would submit that your data would be strengthened by the use of a semi-quantitative pain scale at each period of observation with each patient, allowing each patient to be his or her own control.
Dr Hutter: We didnt do any semi-quantitative evaluation of the pain, since there was no comparison between the two groups.
Dr Molnar: I would like to add a small question to Dr Hutter, whose presentation I enjoyed very much, regarding the numbness and disaesthesia, which is very frequent and can be as bad to the patient as pain, or maybe worse. What is your protocol, or how do you treat or cope with a problem like this, because it is more common than I think we think of it?
Dr Hutter: We dont have any definite therapy for these patients.
Dr Molnar: No vitamins or TENS machines?
Dr Hutter: No. I know some people prescribe vitamins, vitamin B, but I dont know whether those patients took those medications or not.
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