Eur J Cardiothorac Surg 1999;16:S39-S42
© 1999 Elsevier Science NL
Comparison of post-operative pain, stress response, and quality of life in port access vs. standard sternotomy coronary bypass patients
Eugene A Grossi*,
Peter K Zakow,
Greg Ribakove,
Klaus Kallenbach,
Patricia Ursomanno,
Catherine E Gradek,
F Gregory Baumann,
Stephen B Colvin,
Aubrey C Galloway
Division of Cardiothoracic Surgery, Department of Surgery, New York University School of Medicine, New York, NY, USA
* Corresponding author. New York University Medical Center, 530 First Ave., Suite 9V, New York, NY 10016, USA. Tel.: +1-212-263-7452; fax: +1-212-263-5534 (Email: grossi{at}cv.med.nyu.edu).
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Abstract
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Objective: Although it has been postulated that minimally invasive cardiac surgery using the port access method would reduce operative stress and postoperative pain and accelerate postoperative recovery to a good quality of life, few data are currently available to document this intuitively appealing claim. Therefore, this study was designed to examine differences in stress response, postoperative pain, rapidity of recovery, and quality of life after port access (PA) isolated coronary artery bypass surgery compared with standard sternotomy (STD) isolated coronary bypass surgery. Methods: Fourteen PA and 15 STD coronary bypass patients were studied postoperatively for pain score, FEV, catecholamine and cortisol levels, resumption of activity, and Duke Activity Scale ratings. The surgical approach was based on the surgeon's preference. Although the PA patients were younger, there were no other differences between the groups in gender or preoperative risk factors. Results: There were no operative deaths and no differences between the groups in perioperative complications. Repeated measures analysis of variance showed lower pain scale ratings over the first 4 postoperative weeks in the PA group (P<0.001). The PA patients also had less muscle soreness, shortness of breath, fatigue, and poor appetite at 1, 2, 4, and 8 weeks (P<0.05), better FEV at 1 day (1.59 vs. 0.97 l/s; P<0.02) and 3 days (2.20 vs. 1.49 l/s; P<0.03), and lower norepinephrine levels at days 1, 2, and 3 (P=0.005). The Duke Activity Scale questionnaire results demonstrated that more PA patients were able to walk 1–2 blocks at 1 week, climb stairs at 1 and 2 weeks, perform light or moderate housework at 1 and 2 weeks, and engage in moderate recreational activities and perform heavy housework at 4 and 8 weeks (P<0.05). Conclusions: These results show that compared with STD coronary bypass patients PA patients enjoyed significant postoperative physiologic and quality of life advantages with less pain, less early stress response, better pulmonary function, and superior Duke Activity scores during the first 2 postoperative months.
Key Words: Minimally invasive • Pain • Coronary bypass • Quality of life
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1. Introduction
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The recent rapid spread of the port access approach for minimally invasive cardiac surgery is based on the reasonable assumption that the use of a small incision which avoids sternotomy should lead to reduced operative stress, lessened postoperative pain, and a significantly more rapid return of the patient to full activity and a normal life style with no increase in operative mortality or complications. A number of large scale studies are in progress to examine the validity of this assumption, but there is little currently available evidence on either side of the question. Because it seemed that some indicative, if not conclusive, data related to this issue would be most useful if provided as soon as possible, we undertook a detailed and multifaceted study of relatively small comparable groups of patients who were undergoing isolated coronary artery bypass grafting (CABG) by either the port access approach or the standard sternotomy approach. The goals of the study were to compare postoperative pain, stress response, rapidity of recovery, and quality of life by standardized methods and examine whether the port access approach provided significant improvement over standard sternotomy in these respects.
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2. Materials and methods
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The study population comprised 29 patients who underwent isolated coronary artery bypass surgery by either the port access (PA) or the standard sternotomy (STD) approach at our institution between Jan. 1998 and July 1998. Any patient who had suffered a stroke preoperatively was excluded from the study. Choice of approach was based on the surgeon's preference, and 14 patients were operated upon using the PA approach and 15 using the STD approach. All patients gave informed consent to participation in this study, and the study was approved by the appropriate institutional review board. The preoperative characteristics and risk factors of the two patient groups are shown in Table 1
. Details of the port access approach to coronary bypass have been presented elsewhere [1]. Briefly, all port access patients were cannulated via the femoral artery and a triple lumen endoaortic balloon was used to occlude the aorta and to deliver cardioplegic solution. A small left anterior thoracotomy (5–8 cm) was made in the inframammary skin fold; for cases requiring a single right graft the incision was made on the right. All patients received antegrade or retrograde intermittent cold blood cardioplegia.
Data on patient demographics, preoperative risk factors, and perioperative complications were obtained from the Adult Cardiac Surgery Report forms which must be filled out for the New York State Department of Health on every patient who undergoes adult cardiac surgery in that state. Postoperative pain was measured on postoperative days 1, 2, 3, 4, 5, and 7, and at the end of the second and fourth postoperative weeks. Pain was assessed by means of a visual analog scale [2,3]. With this method a 10 cm line marked ‘no pain at all' on the left end and ‘extreme or worst pain' on the right end is shown to the patient who is then asked to indicate the approximate point on the line which indicates his or her current pain level. This point is converted into a number from 1–10 representing the distance from the zero point of the 10 cm line in cm. In another questionnaire related to freedom from pain or discomfort patients were asked whether they were not at all bothered to extremely bothered by muscle soreness, new back pain, shortness of breath, fatigue, nausea, or lack of appetite at 1, 2, 4, and 8 weeks post-op.
Stress related metabolites were measured as cortisol, antidiuretic hormone, norepinephrine, epinephrine, dopamine, and total catecholamines in blood samples obtained pre-op and at 6 h, 1, 2, and 3 days post-op. Standard pulmonary function tests for FEV, FVC, FEV/FVC, and NIF were administered preoperatively and on postoperative days 1 and 3 and after 2 and 6 weeks. Furthermore, the Duke Activity Status Index questionnaire [4] was administered pre-op and at the end of postoperative weeks 1, 2, 4, and 8. This questionnaire measures return to normal functional activity in terms of twelve common activities of daily living, including the patient's ability to walk, climb stairs, work around the house and perform related activities. In addition, as an indication of rapidity of recovery patients were asked to rate their health compared to the pre-op level at postoperative weeks 1, 2, 4, and 8.
All data were entered into a computer and the statistical software SPSS (Chicago, IL) was used to analyze the data. Chi-square analysis was used for categorical variables and the Student's t-test was used for continuous variables. Any measurements which were repeated on the same patient at various intervals were examined by repeated measures analysis of variance.
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3. Results
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Although the STD patients were significantly older than the PA patients, there were no significant differences between the two groups in gender or the incidence of pre-op risk factors (Table 1). There were no operative deaths in either group and no significant differences between groups in the incidences of perioperative complications (Table 2
). A comparison between the two groups of postoperative pain using the visual analog pain scale is shown in Table 3
. For the overall postoperative intervals ranging from one day to four weeks, the PA patients had significantly lower pain scores than did the STD group. In answers to the questionnaire on specific types of pain or discomfort a significantly higher percentage of PA patients compared to STD patients answered that they were not at all or only somewhat bothered by muscle soreness at 1 week (100 vs. 66.7%; P=0.027), by shortness of breath at 1 week (100 vs. 53.3%; P=0.008) and 2 weeks (100 vs. 61.5%; P=0.016), and by fatigue at 2 weeks (100 vs. 38.5%; P=0.001), 4 weeks (92.3 vs. 53.8%; P=0.027), and 8 weeks (100 vs. 54.5%; P=0.008).
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Table 3. Comparison of PA (n=12) and STD (n=13) groups postoperative pain scores (mean±SD) on a basis of 1–10 with 1 being no pain and 10 being the worst possible pain. (P<0.001 by repeated measures analysis of variance)
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Pulmonary function tests were performed preoperatively and at 1 and 3 days and 2 and 6 weeks postoperatively. Measurements were made on 6 patients in each group for FEV, FVC, FEV/FVC, and NIF. The FEV results for the PA patients were significantly higher than for the STD patients at 1 day (1.59 vs. 0.97 l/s; P<0.02) and 3 days (2.20 vs. 1.49 l/s; P<0.03) and all pulmonary function tests showed a trend towards superior recovery of pulmonary function for PA patients. Over the entire postoperative interval being tested, however, the differences in postoperative pulmonary function between the two groups were not statistically significant by repeated measures analysis of variance.
Catecholamines and stress related metabolites were measured in each group as epinephrine, norepinephrine, cortisol, anti-diuretic hormone, dopamine and the combined total concentration of these substances preoperatively and at 6 h and 1, 2, and 3 days post-op. Over the whole postoperative interval norepinephrine levels were significantly lower in the PA group compared to the STD group (P=0.005).
In terms of the postoperative activities which were measured by the Duke Activity Scale questionnaire, a significantly higher percentage of PA patients compared with STD patients were able to walk one to two blocks at 1 week (93.2 vs. 46.7%; P=0.01), climb stairs at 1 and 2 weeks (76.9 vs. 33.3% at 1 week, P=0.021; 92.3 vs. 46.7% at 2 weeks, P=0.010), and engage in moderate recreational activity (58.3 vs. 0%; P=0.002) and heavy housework (83.3 vs. 0%; P=0.002) at 8 weeks. In addition, at postoperative intervals of 2, 4, and 8 weeks patients in each group were asked what was the percentage of overall activity that they could perform compared to prior to their operation. The PA group reported a significantly (P<0.001) higher percentage of return to pre-op activity level than did the STD group (Table 4
).
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Table 4. Comparison of mean postoperative percentage of overall activity compared to pre-op for PA (n=12) and STD (n=12) patient groups. (P<0.001 by repeated measures analysis of variance)
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4. Discussion
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Much has been written about the development of port access minimally invasive coronary bypass surgery [5,6]. and the details of its techniques [1], but because of the approach's relatively short history little has been written regarding whether this technique fulfills its promise of a more rapid and pain-free postoperative recovery. The patients groups being compared in this study were similar in preoperative clinical characteristics (Table 1) and in operative mortality and the incidence of perioperative complications. But the groups showed major differences in what is commonly referred to as quality of life during the postoperative recovery period. Although there is little agreement on how to best define the quality of life after a cardiac surgical procedure [7], minimization of pain would undoubtedly be a major component of most definitions [8,9]. In this study PA patients proved to have significantly less pain at all postoperative intervals sampled from 1 day to 4 weeks. It does not require special inspiration to predict that a patient with a 5–8 cm non-sternal incision will suffer much less pain over the early postoperative recovery period than a patient with a much larger, sternal-splitting incision. Nevertheless, this supposition requires documentation. In addition, in responding to the questionnaire regarding specific types of pain or discomfort PA patients reported significantly less suffering from muscle soreness, shortness of breath, and fatigue during the immediate postoperative period.
Understandably, quality of life is related to exercise capacity as well as freedom from pain [10]. A main goal of coronary bypass surgery is to improve the patient's physical activity by removing angina [11]. Exercise capacity and freedom from pain are inextricably linked, and so it was not surprising to find that a significantly higher percentage of the relatively pain-free PA patients were able to walk 1–2 blocks at 1 week postoperatively and perform other more vigorous activities sooner. Likewise the PA patients showed some signs of better pulmonary function at 1 and 3 days post-op. The analysis of stress related substances yielded results with large standard deviations and larger studies will be required to definitively address this issue.
In conclusion, the results of this study suggest that PA coronary artery bypass patients suffer significantly less postoperative pain and resume the routine activities of life more quickly than patients who undergo coronary bypass using the standard sternotomy approach. Larger clinical studies are of course required to substantiate this indication.
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Footnotes
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Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3–5, 1998.
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References
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- Hlatky MA, Boineau RE, Higginbotham MB, Lee KL, Mark DB, Califf RM, Cobb FR, Pryor DB. A brief self-administered questionnaire to determine functional capacity (The Duke Activity Status Index). Am J Cardiol 1989;64:651-654.[Medline]
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Abstract
1. Introduction
