Though once considered the gold standard, epidural anaesthesia has complications that may be significant and include hypotension, urinary retention, partial or patchy block and, in rare cases, ...devastating neurological injuries also. Paravertebral block (PVB) is an alternative technique for unilateral surgical procedures like thoracotomy, which may offer similar analgesic effectiveness and a more favourable side-effect profile than epidural analgesia. This systematic review and meta-analysis of published randomized clinical trials aims to compare thoracic paravertebral with thoracic epidural analgesia (TEA) in thoracotomy for lung surgery. Five hundred and forty-one patients from 12 clinical trials have been included in this systematic review and meta-analysis. We found that visual analogue scale (VAS) scores at rest and during activity/coughing at 4–8, 24 and 48 h postoperatively were similar in both the PVB and TEA groups. Considering studies not included in the previous meta-analysis, a VAS score on activity at 48 h is significantly better in the PVB group (mean difference 0.40 cm; 95% confidence interval 95% CI 0.77, 0.02; Mantel-Haenszel (M-H) fixed). Hypotension (odds ratio 0.13; 95% CI 0.06, 0.31; M-H fixed) and urinary retention are more common in the epidural analgesia group. So, we conclude that thoracic PVB may be as effective as thoracic epidural analgesia for post-thoracotomy pain relief and is also associated with fewer complications.
Chronic pain complaints after thoracic surgery represent a significant clinical problem in 25–60% of patients. Results from thoracic and other surgical procedures suggest multiple pathogenic ...mechanisms that include pre-, intra-, and postoperative factors. This review attempts to analyse the methodology and systematics of the studies on the post-thoracotomy pain syndrome (PTPS) after lung cancer surgery in adults, in order to clarify the relative role of possible pathogenic factors and to define future strategies for prevention. Literature published from 2000 to 2008 together with studies included in previous systematic reviews was searched recursively using PubMed and OVID by combining three categories of search terms. The available data have major inconsistencies in collection of pre-, intra- and postoperative data that may influence PTPS, thereby hindering precise conclusions as well as preventive and treatment strategies. However, intercostal nerve injury seems to be the most important pathogenic factor. Since there is a general agreement on the clinical relevance of PTPS, a proposal for design of future trials is presented.
Although the benefits of thoracoscopic esophageal atresia repair (TEAR) are well documented, there has been resistance to the uptake of this approach in low- and middle-income countries. This study ...reviews a single unit's experience introducing TEAR in a South African state sector tertiary hospital.
We describe how we set up MIS for esophageal atresia (EA) at our centre. All neonates with EA managed at our institution from January 2016 to January 2022 were included. Excluded patients included those who were not operated on or if data was missing. We compared the different approaches for managing type C EA in our setting. We analyzed the data using the Mann-Whitney U test.
Sixty-five patients were managed with EA over the study duration. There were 54 patients who had type C EA. Thirty-nine patients underwent thoracotomy to repair the defect, and eighteen underwent TEAR, of which sixteen were completed thoracoscopically. There was a statistically significant difference in weight (p-value 0.035), gestational age (p-value 0.002), and age at operation (p-value 0.004) between the groups treated by TEAR and OEAR (open esophageal atresia repair). There was a small median difference in the operative time between TEAR and OEAR of 20 min. The mortality in the OEAR group was higher (20.5 %) compared to the TEAR group (5.5 %), with a p-value of 0.094.
A dedicated quality improvement program focused on introducing MIS for EA can produce results comparable to the open procedure in an LMIC setting.
Survival following emergency department thoracotomy (EDT) for patients in extremis is poor. Whether intervention in the operating room instead of EDT in select patients could lead to improved ...outcomes is unknown. We hypothesized that patients who underwent intervention in the operating room would have improved outcomes compared to those who underwent EDT.
We conducted a retrospective review of the Trauma Quality Improvement Program database from 2017 to 2021. All adult patients who underwent EDT, operating room thoracotomy (ORT), or sternotomy as the first form of surgical intervention within 1 h of arrival were included. Of patients without prehospital cardiac arrest, propensity score matching was utilized to create three comparable groups. The primary outcome was survival. Secondary outcomes included time to procedure.
There were 1865 EDT patients, 835 ORT patients, and 456 sternotomy patients who met the inclusion criteria. There were 349 EDT, 344 ORT, and 408 sternotomy patients in the matched analysis. On Cox multivariate regression, there was an increased risk of mortality with EDT versus sternotomy (HR 4.64, P < 0.0001), EDT versus ORT (HR 1.65, P < 0.0001), and ORT versus sternotomy (HR 2.81, P < 0.0001). Time to procedure was shorter with EDT versus sternotomy (22 min versus 34 min, P < 0.0001) and versus ORT (22 min versus 37 min, P < 0.0001).
There was an association between sternotomy and ORT versus EDT and improved mortality. In select patients, operative approaches rather than the traditional EDT could be considered.
The surgical strategy for congenital diaphragmatic hernia (CDH) repair remains debated and mainly depends on the training and preference of the surgeon. Our aim was to evaluate the occurrence and ...nature of surgical reinterventions within the first year of life, following repair through thoracotomy as compared to laparotomy.
This is a retrospective bi-centric cohort study comparing postero-lateral thoracotomy (n = 55) versus subcostal laparotomy (n = 62) for CDH repair (IRB: MP001882). We included neonates with isolated, left-sided, Bochdalek-type CDH who were operated on between 2000 and 2017, and had a minimum follow-up of 1 year. Excluded were patients treated prenatally and/or had extra-corporeal membrane oxygenation. Outcomes were occurrence and nature of surgical reinterventions and mortality by 1 year of life.
Both groups had comparable neonatal severity risk profiles. The overall surgical reintervention rate by 1 year of age was higher in the thoracotomy group (29.1% vs. 6.5%; p = 0.001), mainly because of a higher prevalence of acute bowel complications (18.1% vs. 3.2%; p = 0.012) requiring surgery, such as perforation, obstruction and volvulus. At 1 year of follow-up, groups were similar in terms of recurrence (5.5% vs. 1.6%; p = 0.341), surgical interventions related to severe gastroesophageal reflux disease (3.6% vs. 1.6%; p = 0.600) and mortality (5.5% vs. 6.6%; p = 1.000).
Postnatal CDH repair through thoracotomy was associated with a higher rate of surgical reinterventions within the first year of life, especially for severe acute gastro-intestinal complications. There seemed to be no difference in recurrence and mortality rate.
Retrospective Comparative Cohort Study.
Level III.
This study aimed to compare respiratory functions of patients after thoracoscopic lobectomy (TS) with those after thoracotomy (TR).
This retrospective study was conducted in two centers, one of which ...adapted TS as a standard procedure in 2009 and the other performs it via TR. Data on patients who underwent lobectomy for congenital lung disease between 2009 and 2021 and underwent pulmonary function test (spirometry) were collected.
Ten patients underwent TS and 36 underwent TR. Distribution based on sex, prenatal diagnosis, pathological diagnosis, and resected lobe were similar between the two groups. The median interquartile range age at procedure in the TR group was significantly smaller than that in the TS group (13 11-18 months versus 38 13-79 months,
= .03). The procedure duration in the TR group was significantly shorter than that in the TS group (230 171-264 minutes versus 264 226-420 minutes,
= .02). Pulmonary function test was conducted at the age of eight in both groups, but the interval between the procedure, and the test was significantly shorter in the TS group (TR: 7 5-8 years versus TS: 5 2-7 years,
= .03). The ratio of forced vital capacity compared to predicted one (TR: 86.6 76.6-95.3 versus TS: 88.7 86.8-89.1,
= .58) and the ratio of forced expiratory volume in 1 second against that predicted (TR: 84.0 80.5-88.7 versus TS: 88.7 86.8-89.1,
= .08) were not significantly different between the two groups.
Although TR was performed earlier than TS, respiratory function was similar between the two groups.
Principle of thoracic damage control surgery Boddaert, Guillaume; Baltazard, Charlotte; Vincent, Yohann ...
Surgery Open Digestive Advance,
July 2024, 2024-07-00, Volume:
15
Journal Article
Background
Minimally invasive repair of congenital heart defects in children has not gained wide popularity yet compared to minimally invasive approaches in adults. We sought to review our experience ...with this approach in children.
Methods
This study included a total of 37 children (24 girls, 64.9%) with a mean age of 6.5 ± 5.1 years, who underwent vertical axillary right minithoracotomy for repair of a variety of congenital heart defects between May 2020 and June 2022.
Results
The mean weight of these children was 25.66 ± 18.3 kg. Trisomy 21 syndrome was present in 3 patients (8.1%). The most common congenital heart defects that were repaired via this approach were atrial septal defects (secundum in 11 patients, 29.7%; primum in 5, 13.5%; and unroofed coronary sinus in 1, 2.7%). Twelve patients (32.4%) underwent repair of partial anomalous pulmonary venous connections with or without sinus venosus defects, while 4 patients (10.8%) underwent closure of membranous ventricular septal defects. Mitral valve repair, resection of cor triatriatum dexter, epicardial pacemaker placement, and myxoma resection occurred in 1 patient (2.7%) each. No early mortality or reoperations. All patients were extubated in the operating room, and the mean length of hospital stay was 3.3 ± 2.04 days. Follow-up was complete (mean 7 ± 5 months). No late mortality or reoperations. One patient required epicardial pacemaker placement due to sinus node dysfunction 5 months after surgery.
Conclusions
Vertical axillary right thoracotomy is a cosmetically superior approach that is safe and effective for repair of a variety of congenital heart defects in children.
Resuscitative thoracotomy is a time-sensitive, lifesaving procedure that may be performed by emergency physicians. The left anterolateral thoracotomy (LAT) is the standard technique commonly used in ...the United States to gain rapid access to critical intrathoracic structures. However, the smaller incision and subsequent limited exposure may not be optimal for the nonsurgical specialist to complete time-sensitive interventions. The modified bilateral anterior clamshell thoracotomy (MCT) developed by Barts Health NHS Trust clinicians at London’s Air Ambulance overcomes these inherent difficulties, maximizes thoracic cavity visualization, and may be the ideal technique for the nonsurgical specialist. The aim of this study is to identify the optimal technique for the nonsurgical-specialist-performed resuscitative thoracotomy. Secondary aims of the study are to identify technical difficulties, procedural concerns, and physician preferences.
Emergency medicine staff and senior resident physicians were recruited from an academic Level I trauma center. Subjects underwent novel standardized didactic and skills-specific training on both the MCT and LAT techniques. Later, subjects were randomized to the order of intervention and performed both techniques on separate fresh, nonfrozen human cadaver specimens. Success was determined by a board-certified surgeon and defined as complete delivery of the heart from the pericardial sac and subsequent 100% occlusion of the descending thoracic aorta with a vascular clamp. The primary outcome was time to successful completion of the resuscitative thoracotomy technique. Secondary outcomes included successful exposure of the heart, successful descending thoracic aortic cross clamping, successful procedural completion, time to exposure of the heart, time to descending thoracic aortic cross-clamp placement, number and type of iatrogenic injuries, correct anatomic structure identification, and poststudy participant questionnaire.
Sixteen emergency physicians were recruited; 15 met inclusion criteria. All participants were either emergency medicine resident (47%) or emergency medicine staff (53%). The median number of previously performed training LATs was 12 (interquartile range 6 to 15) and the median number of previously performed MCTs was 1 (interquartile range 1 to 1). The success rates of our study population for the MCT and LAT techniques were not statistically different (67% versus 40%; difference 27%; 95% confidence interval –61% to 8%). However, staff emergency physicians were significantly more successful with the MCT compared with the LAT (88% versus 25%; difference 63%; 95% CI 9% to 92%). Overall, the MCT also had a significantly higher proportion of injury-free trials compared with the LAT technique (33% versus 0%; difference 33%; 95% CI 57% to 9%). Physician procedure preference favored the MCT over the LAT (87% versus 13%; difference 74%; 95% CI 23% to 97%).
Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.
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