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Cryoanalgesia after thoracotomy
J THoRAc
CARDIOVASC SURG
92:291-295, 1986
Cryoanalgesia after thoracotomy Improvement of technique and review of 600 cases The efficacy of cryoanalgesia for the control of post-thoracotomy pain has led to the acceptance of the technique as a routine procedure in this unit. A study of 600 consecutive patients in whom an improved technique was usedis not reported. The freezing timefor each intercostalnerve in this groupwas reduced to one 30 second exposure instead of the two 30 second exposures previously used. This reduced the duration of cutaneous numbness, with no loss of pain control Freezingabove the fifth intercostal nerve is no longer practiced in women. Modification to the probe has simplified the procedure. Pulmonary function studies and blood-gas analysis are also described.
M. O. Maiwand, M.D., A. R. Makey, M.S., F.R.C.S., and A. Rees, F.R.C.S., London and Middlesex, England
M
any different methods have been used to control post-thoracotomy pain and reduce the incidence of complications associated with this procedure.!" Because the preliminary study? showed that cryoanalgesia is simple, well controlled, and provides effective and prolonged analgesia in 79% of patients, the procedure has been accepted in this hospital as a routine method for control of post-thoracotomy pain and has been adopted by others." Initially the mean duration of numbness in the treated area (6 to 9 months) was longer than ideal. Therefore, the freezing time was reduced to one 30 second exposure. Freezing above the fifth intercostal nerve in women is no longer performed to avoid the unpleasant loss of sensation in the breast area.
Patients and methods Six hundred consecutive patients (451 male and 149 female patients) were subjected to one freezing cycle (30 seconds) for control of post-thoracotomy pain. Their mean age was 58 years and the age range was 13 to 82 years. The surgical procedures performed are listed in Table I. From Colindale and Charing Cross Hospitals, London, England, and Hareficld Hospital, Middlesex, England. Received for publication April 30, 1985. Accepted for publication Nov. 4, 1985. Address for reprints: M. O. Maiwand, M.D., Consultant Thoracic Surgeon, Colindale Hospital, Colindale Ave., London, N.W.9., England.
Table I. Surgical procedures Percentage of total
Procedure Lobectomy Explora tory thoracotomy and lung biopsy Pneumonectomy Pleurectomy Esophageal procedure (including repair of hiatus hernia) Decortication Segmental and wedge resection Thoracotomy for excision of cyst Removal of mediastinal tumor Total
36.1 15.5 89 78 63
14.9 13.0 10.5
28 23
4.7 3.8
5
0.8
4
0.7
600
100
Originally the parietal pleura was peeled back to assist in the accurate location of the intercostal nerves.' With increased experience we have found this can be avoided in patients with thin pleura, but if the pleura is thickened local peeling of pleura is advisable. Accurate positioning of the probe tip on each intercostal nerve close to the intercostal foramen proximal to the collateral branch (Fig. I) for 30 seconds produced an ice ball approximately 2 to 3 mm in diameter. The intercostal nerve at the thoracotomy space (sixth or seventh) and two intercostal nerves above the two below the space were frozen. The probe was allowed to defrost 291
292
The Journal of Thoracic and Cardiovascular Surgery
Maiwand, Makey, Rees
Fig. 2. The Spembly cryounit.
in situ to facilitate its removal. A new curved probe was designed to improve the procedure technically. It has a thermally insulated stem approximately 3 rom in diameter. The probe is fitted with an uninsulated trocarshaped end that allows physical fixation of the nerve. The probe is connected to high-pressure (700 psi) nitrous oxide gas, which is controlled via a Spembly 140
cryo unit (Fig. 2). The resultant Joule-Thomson effect produces rapid cooling of the tip. Chest drains were placed within the cryotreated spaces to take advantage of the analgesic area. During the procedure tissue temperatures were measured on 100 consecutive patients from the 600 studied, with a fine thermocouple needle (0.6 rom in diameter)
Volume 92 Number 2
Cryoanalgesia after thoracotomy
August, 1986
29 3
31.2%
t ~
30
27.2%
~
::/-
~ /
~
-:
v
;::
rvr:::
17%
20
r:
/
/
/
V
f
r
v
/
-
15.B%
/
10
,
8.4%
-
V
•
/ /
-
/
,-
./
~
I::: V:'
/
Age
0-40
41-50
51-60
&1-70
71-80
n l.n
81-90
Fig. 3. Age distribution of patients treated.
Table n. Pain relief obtained in Group A (one freeze cycle) compared with Group B (two freeze cycles) No. of patients Percentage of patients free from postop. discomfort Percentage of patients with mild postop, pain Percentage of patients with severe postop. pain Mean duration of analgesia (days) Mean duration of numbness (days)
Group A
Group B
600 83
100 79
10
12
7
9
27
30
38
91
placed very close to the probe tip. A postoperative narcotic, papaveretum or pethidine (meperidine hydrochloride), was given only when needed. The duration of analgesia at the operative site and cutaneous numbness of the chest and anterior abdominal wall were recorded postoperatively at 3 week intervals.
Table m. Analgesic requirement of Group A (one freeze cycle) and Group B (two freeze cycles) Group A No. of patients Mean No. of narcotic injections per patient (0-48 hr) postop. Percentage of patients needing oral analgesia postop, Mean duration of requirement for oral analgesia* (wk)
600
0.87
Group B 100 1.53
21
18
3-6
4-8
'The analgesics given were daraphen (distalgcsic, U.K.) and acetaminophen (Panadol).
Respiratory function tests were performed 24 and 48 hours postoperatively on 50 consecutive patients, who formed a subgroup of the 600. Each test was repeated three 'times and the mean value recorded. In addition, arterial blood-gas levels were measured immediately before the respiratory function tests and when the patients had not received oxygen for at least half an hour.
294 Maiwand, Makey, Rees
Results Table II compares the pain relief obtained in 600 patients with one freeze cycle (Group A) with an initial study of 100 patients with two freeze cycles (Group B). The mean duration of numbness extending to the anterior chest wall and epigastric area in Group A was a mean of 38 days and in Group B a mean of91 days. The table also shows that the mean duration of analgesia in Group A was 27 days and in Group B 30 days. Table III shows the postoperative analgesic requirements of the two groups. Tissue recordings made on 100 consecutive patients during the procedure showed a mean temperature of approximately -20 C. This produced prolonged interruption of nerve conduction and allowed recovery of function by axonal regeneration. The results of respiratory function tests showed the vital capacity returning to an average of 65% of its preoperative value within 48 hours. These results compared favorably with the results reported by other authors":" using an alternative method of pain relief. The blood-gas studies showed a rapid restoration of arterial oxygen and carbon dioxide tensions to normal levels. 0
Discussion Comparison of the two groups shows that equally good results are obtained from one 30 second freeze as from two, with the advantage that the duration - of cutaneous numbness is shortened. The clinical findings confirm that single 30 second freezing produces effective analgesia followed by nerve regeneration. Any further shortening of the freezing time might result in inadequate relief of pain. Even the 17% of patients who were not pain free had little pain on manipulation of the chest drains and cooperated readily with physiotherapy. Return of cutaneous sensation to normal has been shortened by one freeze compared to two freezes (mean of 38 days versus 91 days). Because this method is now standard practice in this unit, comparison with alternative methods of pain control is not desirable, in our opinion. An unpleasant rigid feeling of the chest wall was reported by 18% of patients. Bulging of the ipsilateral abdominal wall occured when intercostal nerves were cryotreated. These features disappeared with the regeneration of the nerves. Early postoperative back pain of varying severity was mentioned by a significant number of patients. Straining of the ligaments of the costovertebral and costotransverse joints by retraction of intercostal spaces and lateral positioning of the patient on the operating table are
The Journal of Thoracic and Cardiovascular Surgery
thought to be responsible. In addition, the technique does not freeze the posterior primary rami of the intercostal nerves that mediate sensation from the area of back pain. Four female patients admitted to distress because of the loss of sensation in the nipple area of the breast and loss of response to mammary stimulus. Although sensation returned normally without complications with nerve regeneration, cooling of the fifth and higher intercostal nerves has been avoided in young women. A large percentage of older patients were readily accepted for surgical treatment (Fig. 3), because postthoracotomy restoration of mobility and the response to physiotherapy even in this age group were equally good. Bronchopleural fistula, a widely recognized complication of lung resection,' J, 14 occurred in only three patients (0.5%). Wound dehiscence was seen in 2%. Because the surgical technique is unchanged, these results indicate an additional advantage of cryoanalgesia. Bleeding complications did not occur as a result of the technique. There have been no ill effects to operator, assistant, or nursing staff as a result of use of the cryosurgical procedure. We acknowledge the help of the consultant anaesthetist, nursing, physiotherapy, pathology, cardia-respiratory, and x-ray staff at Colindale Hospital. Manufacturers of the machine--Spembly Limited, Newbury Road, Andover, Hampshire, England-provided technical assistance. REFERENCES Moore DC: Intercostal nerve block for post-operative somatic pain following surgery of the thorax and upper abdomen. Br J Anaesth 47:284-288, 1975 2 Cundy JM: Improved pain relief after thoracotomy. Br Med J 283:1185, 1981 3 Griffiths DPG, Diamond AW, Cameron JD: Post-operative extradural analgesia following thoracic surgery. A feasibility study. Br J Anaesth 47:48-55, 1975 4 James EC, Kolberg HL, Iwen GW, Gellatly TA, Forks G: Epidural analgesia for post-thoracotomy patients. J THORAC CARDIOV ASC SURG 82:898-903, 1981 5 Abbey Smith R: Pain relief after thoracotomy. Lancet 1:815-816,1976
6 Simpson BRJ, Parkhouse J, Marshall R, Lambrechts W: Extradural analgesia and the prevention of post-operative respiratory complications. Br J Anaesth 33:628-641, 1961 7 Maiwand MO, Makey AR: Cryoanalgesia for relief of pain after thorocotomy. Br Med J 282:1749-1750, 1981 8 Gothard JWW: Pain reliefafter thoracotomy (letter). Br J Anaesth 37:599-600, 1982
9 Galway JE, Caves PK: Effects of intercostal nerve block-
Volume 92 Number 2
August, 1986
ade during operation on lung function and relief of pain following thoracotomy. Br J Anaesth 47:730-735, 1975 10 Delikan AE, Lee CK, Young NK, Ong SC, Ganendran A: Post-operative local analgesia for thoracotomy with direct bupivacaine intercostal blocks. Anaesthesia 28:561-567, 1973 11 Faust RJ, Nauss LA: Post-thoracotomy intercostal block. Comparisons of its effect on pulmonary function with those of intramuscular meperidine. Anaesth Analg 55:542-546, 1976
Cryoanalgesia after thoracotomy 2 9 5
12 Toledo-Pereyra LH, DeMeester TR: Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function. Ann Thorac Surg 27:203-205, 1979 13 Forrester-Wood CP: Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus. J THORAC CARDIOVASC SURG 80:406-409, 1980 14 Milstein MH: Role of automatic staplers in the aetiology of bronchopleural fistula. Thorax 40:27-31, 1985
Bound volumes available to subscribers Bound volumes of THE JOURNAL OFTHORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1986 issues from the Publisher, at a cost of $49.00 ($66.00 international) for Vol. 91 (January-June) and Vol. 92 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
CARDIOVASC SURG
92:291-295, 1986
Cryoanalgesia after thoracotomy Improvement of technique and review of 600 cases The efficacy of cryoanalgesia for the control of post-thoracotomy pain has led to the acceptance of the technique as a routine procedure in this unit. A study of 600 consecutive patients in whom an improved technique was usedis not reported. The freezing timefor each intercostalnerve in this groupwas reduced to one 30 second exposure instead of the two 30 second exposures previously used. This reduced the duration of cutaneous numbness, with no loss of pain control Freezingabove the fifth intercostal nerve is no longer practiced in women. Modification to the probe has simplified the procedure. Pulmonary function studies and blood-gas analysis are also described.
M. O. Maiwand, M.D., A. R. Makey, M.S., F.R.C.S., and A. Rees, F.R.C.S., London and Middlesex, England
M
any different methods have been used to control post-thoracotomy pain and reduce the incidence of complications associated with this procedure.!" Because the preliminary study? showed that cryoanalgesia is simple, well controlled, and provides effective and prolonged analgesia in 79% of patients, the procedure has been accepted in this hospital as a routine method for control of post-thoracotomy pain and has been adopted by others." Initially the mean duration of numbness in the treated area (6 to 9 months) was longer than ideal. Therefore, the freezing time was reduced to one 30 second exposure. Freezing above the fifth intercostal nerve in women is no longer performed to avoid the unpleasant loss of sensation in the breast area.
Patients and methods Six hundred consecutive patients (451 male and 149 female patients) were subjected to one freezing cycle (30 seconds) for control of post-thoracotomy pain. Their mean age was 58 years and the age range was 13 to 82 years. The surgical procedures performed are listed in Table I. From Colindale and Charing Cross Hospitals, London, England, and Hareficld Hospital, Middlesex, England. Received for publication April 30, 1985. Accepted for publication Nov. 4, 1985. Address for reprints: M. O. Maiwand, M.D., Consultant Thoracic Surgeon, Colindale Hospital, Colindale Ave., London, N.W.9., England.
Table I. Surgical procedures Percentage of total
Procedure Lobectomy Explora tory thoracotomy and lung biopsy Pneumonectomy Pleurectomy Esophageal procedure (including repair of hiatus hernia) Decortication Segmental and wedge resection Thoracotomy for excision of cyst Removal of mediastinal tumor Total
36.1 15.5 89 78 63
14.9 13.0 10.5
28 23
4.7 3.8
5
0.8
4
0.7
600
100
Originally the parietal pleura was peeled back to assist in the accurate location of the intercostal nerves.' With increased experience we have found this can be avoided in patients with thin pleura, but if the pleura is thickened local peeling of pleura is advisable. Accurate positioning of the probe tip on each intercostal nerve close to the intercostal foramen proximal to the collateral branch (Fig. I) for 30 seconds produced an ice ball approximately 2 to 3 mm in diameter. The intercostal nerve at the thoracotomy space (sixth or seventh) and two intercostal nerves above the two below the space were frozen. The probe was allowed to defrost 291
292
The Journal of Thoracic and Cardiovascular Surgery
Maiwand, Makey, Rees
Fig. 2. The Spembly cryounit.
in situ to facilitate its removal. A new curved probe was designed to improve the procedure technically. It has a thermally insulated stem approximately 3 rom in diameter. The probe is fitted with an uninsulated trocarshaped end that allows physical fixation of the nerve. The probe is connected to high-pressure (700 psi) nitrous oxide gas, which is controlled via a Spembly 140
cryo unit (Fig. 2). The resultant Joule-Thomson effect produces rapid cooling of the tip. Chest drains were placed within the cryotreated spaces to take advantage of the analgesic area. During the procedure tissue temperatures were measured on 100 consecutive patients from the 600 studied, with a fine thermocouple needle (0.6 rom in diameter)
Volume 92 Number 2
Cryoanalgesia after thoracotomy
August, 1986
29 3
31.2%
t ~
30
27.2%
~
::/-
~ /
~
-:
v
;::
rvr:::
17%
20
r:
/
/
/
V
f
r
v
/
-
15.B%
/
10
,
8.4%
-
V
•
/ /
-
/
,-
./
~
I::: V:'
/
Age
0-40
41-50
51-60
&1-70
71-80
n l.n
81-90
Fig. 3. Age distribution of patients treated.
Table n. Pain relief obtained in Group A (one freeze cycle) compared with Group B (two freeze cycles) No. of patients Percentage of patients free from postop. discomfort Percentage of patients with mild postop, pain Percentage of patients with severe postop. pain Mean duration of analgesia (days) Mean duration of numbness (days)
Group A
Group B
600 83
100 79
10
12
7
9
27
30
38
91
placed very close to the probe tip. A postoperative narcotic, papaveretum or pethidine (meperidine hydrochloride), was given only when needed. The duration of analgesia at the operative site and cutaneous numbness of the chest and anterior abdominal wall were recorded postoperatively at 3 week intervals.
Table m. Analgesic requirement of Group A (one freeze cycle) and Group B (two freeze cycles) Group A No. of patients Mean No. of narcotic injections per patient (0-48 hr) postop. Percentage of patients needing oral analgesia postop, Mean duration of requirement for oral analgesia* (wk)
600
0.87
Group B 100 1.53
21
18
3-6
4-8
'The analgesics given were daraphen (distalgcsic, U.K.) and acetaminophen (Panadol).
Respiratory function tests were performed 24 and 48 hours postoperatively on 50 consecutive patients, who formed a subgroup of the 600. Each test was repeated three 'times and the mean value recorded. In addition, arterial blood-gas levels were measured immediately before the respiratory function tests and when the patients had not received oxygen for at least half an hour.
294 Maiwand, Makey, Rees
Results Table II compares the pain relief obtained in 600 patients with one freeze cycle (Group A) with an initial study of 100 patients with two freeze cycles (Group B). The mean duration of numbness extending to the anterior chest wall and epigastric area in Group A was a mean of 38 days and in Group B a mean of91 days. The table also shows that the mean duration of analgesia in Group A was 27 days and in Group B 30 days. Table III shows the postoperative analgesic requirements of the two groups. Tissue recordings made on 100 consecutive patients during the procedure showed a mean temperature of approximately -20 C. This produced prolonged interruption of nerve conduction and allowed recovery of function by axonal regeneration. The results of respiratory function tests showed the vital capacity returning to an average of 65% of its preoperative value within 48 hours. These results compared favorably with the results reported by other authors":" using an alternative method of pain relief. The blood-gas studies showed a rapid restoration of arterial oxygen and carbon dioxide tensions to normal levels. 0
Discussion Comparison of the two groups shows that equally good results are obtained from one 30 second freeze as from two, with the advantage that the duration - of cutaneous numbness is shortened. The clinical findings confirm that single 30 second freezing produces effective analgesia followed by nerve regeneration. Any further shortening of the freezing time might result in inadequate relief of pain. Even the 17% of patients who were not pain free had little pain on manipulation of the chest drains and cooperated readily with physiotherapy. Return of cutaneous sensation to normal has been shortened by one freeze compared to two freezes (mean of 38 days versus 91 days). Because this method is now standard practice in this unit, comparison with alternative methods of pain control is not desirable, in our opinion. An unpleasant rigid feeling of the chest wall was reported by 18% of patients. Bulging of the ipsilateral abdominal wall occured when intercostal nerves were cryotreated. These features disappeared with the regeneration of the nerves. Early postoperative back pain of varying severity was mentioned by a significant number of patients. Straining of the ligaments of the costovertebral and costotransverse joints by retraction of intercostal spaces and lateral positioning of the patient on the operating table are
The Journal of Thoracic and Cardiovascular Surgery
thought to be responsible. In addition, the technique does not freeze the posterior primary rami of the intercostal nerves that mediate sensation from the area of back pain. Four female patients admitted to distress because of the loss of sensation in the nipple area of the breast and loss of response to mammary stimulus. Although sensation returned normally without complications with nerve regeneration, cooling of the fifth and higher intercostal nerves has been avoided in young women. A large percentage of older patients were readily accepted for surgical treatment (Fig. 3), because postthoracotomy restoration of mobility and the response to physiotherapy even in this age group were equally good. Bronchopleural fistula, a widely recognized complication of lung resection,' J, 14 occurred in only three patients (0.5%). Wound dehiscence was seen in 2%. Because the surgical technique is unchanged, these results indicate an additional advantage of cryoanalgesia. Bleeding complications did not occur as a result of the technique. There have been no ill effects to operator, assistant, or nursing staff as a result of use of the cryosurgical procedure. We acknowledge the help of the consultant anaesthetist, nursing, physiotherapy, pathology, cardia-respiratory, and x-ray staff at Colindale Hospital. Manufacturers of the machine--Spembly Limited, Newbury Road, Andover, Hampshire, England-provided technical assistance. REFERENCES Moore DC: Intercostal nerve block for post-operative somatic pain following surgery of the thorax and upper abdomen. Br J Anaesth 47:284-288, 1975 2 Cundy JM: Improved pain relief after thoracotomy. Br Med J 283:1185, 1981 3 Griffiths DPG, Diamond AW, Cameron JD: Post-operative extradural analgesia following thoracic surgery. A feasibility study. Br J Anaesth 47:48-55, 1975 4 James EC, Kolberg HL, Iwen GW, Gellatly TA, Forks G: Epidural analgesia for post-thoracotomy patients. J THORAC CARDIOV ASC SURG 82:898-903, 1981 5 Abbey Smith R: Pain relief after thoracotomy. Lancet 1:815-816,1976
6 Simpson BRJ, Parkhouse J, Marshall R, Lambrechts W: Extradural analgesia and the prevention of post-operative respiratory complications. Br J Anaesth 33:628-641, 1961 7 Maiwand MO, Makey AR: Cryoanalgesia for relief of pain after thorocotomy. Br Med J 282:1749-1750, 1981 8 Gothard JWW: Pain reliefafter thoracotomy (letter). Br J Anaesth 37:599-600, 1982
9 Galway JE, Caves PK: Effects of intercostal nerve block-
Volume 92 Number 2
August, 1986
ade during operation on lung function and relief of pain following thoracotomy. Br J Anaesth 47:730-735, 1975 10 Delikan AE, Lee CK, Young NK, Ong SC, Ganendran A: Post-operative local analgesia for thoracotomy with direct bupivacaine intercostal blocks. Anaesthesia 28:561-567, 1973 11 Faust RJ, Nauss LA: Post-thoracotomy intercostal block. Comparisons of its effect on pulmonary function with those of intramuscular meperidine. Anaesth Analg 55:542-546, 1976
Cryoanalgesia after thoracotomy 2 9 5
12 Toledo-Pereyra LH, DeMeester TR: Prospective randomized evaluation of intrathoracic intercostal nerve block with bupivacaine on postoperative ventilatory function. Ann Thorac Surg 27:203-205, 1979 13 Forrester-Wood CP: Bronchopleural fistula following pneumonectomy for carcinoma of the bronchus. J THORAC CARDIOVASC SURG 80:406-409, 1980 14 Milstein MH: Role of automatic staplers in the aetiology of bronchopleural fistula. Thorax 40:27-31, 1985
Bound volumes available to subscribers Bound volumes of THE JOURNAL OFTHORACIC AND CARDIOVASCULAR SURGERY are available to subscribers (only) for the 1986 issues from the Publisher, at a cost of $49.00 ($66.00 international) for Vol. 91 (January-June) and Vol. 92 (July-December). Shipping charges are included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must accompany all orders. Contact The C. V. Mosby Company, Circulation Department, 11830 Westline Industrial Drive, St. Louis, Missouri 63146, USA; phone (800) 325-4177, ext. 351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.