- Email: [email protected]
Paravertebral, extrapleural infusion for the management of post-thoracotomy pain
Therapy -
Surgery
[•} Tuesday, 12 September 2000
10:30-12:00
ORAL SESSION
Surge~/Miscellaneous
1
•
3
•
Omento-myoplasty for post surgical pleural fistula
M. Giovanni, G. Furlan, L. Politi, A. Terzi, A. Lonardoni, F. Calabr&
Divisione di Chirurgia Toracica, Azienda Osp. di Verona, Ospedale Borgo Trento, Verona, Italy We have to consider the Bronchopleural Fistula (BPF) one of the major complications in resective pulmonary surgery. The modern reported incidence of BPF after pulmonary resection varies from 2.1% to 10%. When it appears, it carries a mortality ranging from 16.4% to 71.2%, and so we must adopt all the modalities to try to avoid this often deadly complication. In the department of Thoracic Surgery, Verona, from 1989 to 1999 n. 4056 patients were treated with pulmonary resections for neoplastic or infective pathologies. In this series we have 55 (1.4%) BPF. Of these 55 patients, 15 (27.2%) died, 5 where discarged with chest tube or open window and 35 treated in a second time with omento-myoplasty. The median time from the two operations was 265 days (range from 1 to 462). In our series the muscles we use, with or without omento were latissimus dorsi, pectoralis mayor, dentatus and dyaphragm. We have two deaths (6%) so the final mortality rate for BPF was 30.9%. The primitive operations were 21 pneumonectomies (13 right, 8 left) and 14 Iobectomies. All the primitive operations were performed from the same equipe of surgeons, used the same tecnique of manual bronchial stump closure (wyclril 3-0) and covered the stump with a vascularized mediastinal flap. No patients were treated with preoperative radiotherapy, and 7 only postoperatively. At the suspect of BPF (fever, shortness of breath, etc), we routinely performed a bronchoscopy to asses the presence and the size. The first bronchoscopy was diagnostic in 89% of patients. In no cases was performed ventilatory scintigraphy. We have to divide the risk factors in non operative and operative. In the first group we have considered pre and postoperative irradiation, malnutrition, hepatic cirrosis, advanced age, hypoabuminemya, diabetes and steroid administration; in the second group the extreme radical lymphadenectomy which reduce the blood supply to the bronchial stump: it must not be too long, the suture without tension and the certainty of disease-free bronchial margins (frozen sections) must be assured. Another important risk factor is the mechanical ventilation with high air flows after the operation. When BPF appears, we think that, following the acute phase treated by chest tube or open window, the final and definitive possibility of cure is an intrathoracic muscle and/or omento trasposition and chest wall closure. Anyway, the best way to manage postoperative BPF is to reduce the risk factors before, during and after the pulmonary resection.
Paravertebral, extrapleural infusion for the management of post-thoracotomy pain
D. Bimston, J.-P. McGee, M. Liptay, W. Fry. Dept. of Surgery, Evanston Northwestern Healthcare, Evanston, IL, USA Continuous thoracic epidural analgesia (EPI) is considered to be the gold standard for post-thoracotomy pain control. Epidurals are, however, associated with their own complications such as problems with catheter placement, respiratory depression, and urinary retention. A new technique of continuous paravertebral, extrapleural infusion (PARA) has been described which provides equivalent analgesia with possibly fewer side effects. In a prospective study, 50 patients were randomized to receive either a PAPA or an EPI for post-thoracotomy pain control. The EPI catheters were placed preoperatively by the anesthesiologist. The PARA catheters were placed subpleurally by the thoracic surgeon at the time of chest closure. Analgesic infusions consisted of fentanyl 10 mcg/ml and bupivacaine 0.1% in normal saline. We found that both methods provided adequate postoperative pain control. The EPI produced slightly better analgesia during the first 24 hours postoperative when measured by visual analog scores. Neither group demonstrated a greater number of pain-related complications. There was no statistically significant difference in analgesia, FVC, FEV1, drug levels of either fentanyl or bupivacaine, or hospital stay. There was, however, a 29% incidence of urinary retention in the EPI group compared to a zero incidence in the PARA group for a p-value of 0.002. Since the incidence of urinary retention is lower and the catheter can be placed with much more speed and ease in the PAPA technique, we recommend continuous PAPA infusion as the method of choice for post-thoracotomy analgesia.
•]
Pulmonary function changes after induction chemotherapy with cisplatinum and gemcitabine in stage III non small cell lung cancer. Any additional risk for surgery?
F. Leo, IR Solli, G. Veronesi, M. D'Aiuto, C. Ratcliffe, F. D'Ovidio, U. Pastorino. European Insitute of Oncology, Milan; Thoracic Surgery
Department, European Institute of Oncology, Italy Patients with lung cancer receiving chemotherapy experience changes in their respiratory function, usually improving their spiromerty values and decreasing diffusion capacity for carbon monoxide (DLCO). The aim of the study was to test lung toxicity of a cisplatinum-gemcitabine based regimen (3 courses of cisplatinum 80 mg/m2 day 1, 21 and gemcitabine 1250 mg/m2 day 1, 8, 21) for stage III non small cell lung cancer (nsclc) and verify the impact of respiratory function changes on surgical risk after chemotherapy. From November 1998, 21 consecutive patients entered a prospective study testing spirometry, DIco, blood gas analysis, baseline dyspneoa index evaluation, chest X-ray and spiral chest CT scan before and after 3 courses of chemotherapy. Loss of 20% or more in any considered parameter was defined as subclinical lung toxicity. All patients completed the treatment; no episode of clinically evident pulmonary toxicity was recorded. Transition dyspneoa score showed a slight improvement in 13 patients (range +2/+4) and an unmodified score in 8 patients. FEV1 and FVC showed a clear improvement after chemotherapy (median FEV1 2.04 vs 2.37, p .03, median FVC 2.77 vs 3.03, p .02). Arterial blood oxygen tension increased significantly in all but two patients (median value from 78 to 89 mmHg, p .02). On the contrary, median DLCO decreased from 6.1 to 5.6 (p .02) and DLCO% from 72% to 63.7%. Three patients (14.3%) had a decrease in DLCO% of more than 20% without any respiratory sign or symptom. Difusion capacity adjusted for alveolar
Surgery
[•} Tuesday, 12 September 2000
10:30-12:00
ORAL SESSION
Surge~/Miscellaneous
1
•
3
•
Omento-myoplasty for post surgical pleural fistula
M. Giovanni, G. Furlan, L. Politi, A. Terzi, A. Lonardoni, F. Calabr&
Divisione di Chirurgia Toracica, Azienda Osp. di Verona, Ospedale Borgo Trento, Verona, Italy We have to consider the Bronchopleural Fistula (BPF) one of the major complications in resective pulmonary surgery. The modern reported incidence of BPF after pulmonary resection varies from 2.1% to 10%. When it appears, it carries a mortality ranging from 16.4% to 71.2%, and so we must adopt all the modalities to try to avoid this often deadly complication. In the department of Thoracic Surgery, Verona, from 1989 to 1999 n. 4056 patients were treated with pulmonary resections for neoplastic or infective pathologies. In this series we have 55 (1.4%) BPF. Of these 55 patients, 15 (27.2%) died, 5 where discarged with chest tube or open window and 35 treated in a second time with omento-myoplasty. The median time from the two operations was 265 days (range from 1 to 462). In our series the muscles we use, with or without omento were latissimus dorsi, pectoralis mayor, dentatus and dyaphragm. We have two deaths (6%) so the final mortality rate for BPF was 30.9%. The primitive operations were 21 pneumonectomies (13 right, 8 left) and 14 Iobectomies. All the primitive operations were performed from the same equipe of surgeons, used the same tecnique of manual bronchial stump closure (wyclril 3-0) and covered the stump with a vascularized mediastinal flap. No patients were treated with preoperative radiotherapy, and 7 only postoperatively. At the suspect of BPF (fever, shortness of breath, etc), we routinely performed a bronchoscopy to asses the presence and the size. The first bronchoscopy was diagnostic in 89% of patients. In no cases was performed ventilatory scintigraphy. We have to divide the risk factors in non operative and operative. In the first group we have considered pre and postoperative irradiation, malnutrition, hepatic cirrosis, advanced age, hypoabuminemya, diabetes and steroid administration; in the second group the extreme radical lymphadenectomy which reduce the blood supply to the bronchial stump: it must not be too long, the suture without tension and the certainty of disease-free bronchial margins (frozen sections) must be assured. Another important risk factor is the mechanical ventilation with high air flows after the operation. When BPF appears, we think that, following the acute phase treated by chest tube or open window, the final and definitive possibility of cure is an intrathoracic muscle and/or omento trasposition and chest wall closure. Anyway, the best way to manage postoperative BPF is to reduce the risk factors before, during and after the pulmonary resection.
Paravertebral, extrapleural infusion for the management of post-thoracotomy pain
D. Bimston, J.-P. McGee, M. Liptay, W. Fry. Dept. of Surgery, Evanston Northwestern Healthcare, Evanston, IL, USA Continuous thoracic epidural analgesia (EPI) is considered to be the gold standard for post-thoracotomy pain control. Epidurals are, however, associated with their own complications such as problems with catheter placement, respiratory depression, and urinary retention. A new technique of continuous paravertebral, extrapleural infusion (PARA) has been described which provides equivalent analgesia with possibly fewer side effects. In a prospective study, 50 patients were randomized to receive either a PAPA or an EPI for post-thoracotomy pain control. The EPI catheters were placed preoperatively by the anesthesiologist. The PARA catheters were placed subpleurally by the thoracic surgeon at the time of chest closure. Analgesic infusions consisted of fentanyl 10 mcg/ml and bupivacaine 0.1% in normal saline. We found that both methods provided adequate postoperative pain control. The EPI produced slightly better analgesia during the first 24 hours postoperative when measured by visual analog scores. Neither group demonstrated a greater number of pain-related complications. There was no statistically significant difference in analgesia, FVC, FEV1, drug levels of either fentanyl or bupivacaine, or hospital stay. There was, however, a 29% incidence of urinary retention in the EPI group compared to a zero incidence in the PARA group for a p-value of 0.002. Since the incidence of urinary retention is lower and the catheter can be placed with much more speed and ease in the PAPA technique, we recommend continuous PAPA infusion as the method of choice for post-thoracotomy analgesia.
•]
Pulmonary function changes after induction chemotherapy with cisplatinum and gemcitabine in stage III non small cell lung cancer. Any additional risk for surgery?
F. Leo, IR Solli, G. Veronesi, M. D'Aiuto, C. Ratcliffe, F. D'Ovidio, U. Pastorino. European Insitute of Oncology, Milan; Thoracic Surgery
Department, European Institute of Oncology, Italy Patients with lung cancer receiving chemotherapy experience changes in their respiratory function, usually improving their spiromerty values and decreasing diffusion capacity for carbon monoxide (DLCO). The aim of the study was to test lung toxicity of a cisplatinum-gemcitabine based regimen (3 courses of cisplatinum 80 mg/m2 day 1, 21 and gemcitabine 1250 mg/m2 day 1, 8, 21) for stage III non small cell lung cancer (nsclc) and verify the impact of respiratory function changes on surgical risk after chemotherapy. From November 1998, 21 consecutive patients entered a prospective study testing spirometry, DIco, blood gas analysis, baseline dyspneoa index evaluation, chest X-ray and spiral chest CT scan before and after 3 courses of chemotherapy. Loss of 20% or more in any considered parameter was defined as subclinical lung toxicity. All patients completed the treatment; no episode of clinically evident pulmonary toxicity was recorded. Transition dyspneoa score showed a slight improvement in 13 patients (range +2/+4) and an unmodified score in 8 patients. FEV1 and FVC showed a clear improvement after chemotherapy (median FEV1 2.04 vs 2.37, p .03, median FVC 2.77 vs 3.03, p .02). Arterial blood oxygen tension increased significantly in all but two patients (median value from 78 to 89 mmHg, p .02). On the contrary, median DLCO decreased from 6.1 to 5.6 (p .02) and DLCO% from 72% to 63.7%. Three patients (14.3%) had a decrease in DLCO% of more than 20% without any respiratory sign or symptom. Difusion capacity adjusted for alveolar