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Eur J Cardiothorac Surg 2000;18:7-11
© 2000 Elsevier Science NL

Early and long-term complaints following video-assisted thoracoscopic surgery: evaluation in 173 patients

Division of Thoracic Surgery, University Hospital, Rämistrasse 100, CH-8091 Zürich, Switzerland

Received 8 September 1999; received in revised form 18 February 2000; accepted 7 March 2000.

Corresponding author. Tel.: +41-1-255-8802; fax: +41-1-255-8805
e-mail: walter.weder{at}chi.usz.ch

	Abstract

Top Abstract 1. Introduction 2. Material and methods... 3. Results 4. Discussion Appendix A. Conference... References

 
Objective: Minimal invasive surgical techniques have gained high acceptance in thoracic surgery during the last 10 years. However, up to now, only scant information exists on chronic postoperative pain and discomfort in patients who underwent video-assisted thoracoscopy. Therefore, a retrospective study was performed with the aid of a self-reported questionnaire. Methods: Two hundred and thirteen patients (of whom 79 females) with a mean age of 48 (range 15–88) years were operated on for a total of 225 procedures. Thoracoscopy was performed for pneumothorax (n=70), pulmonary nodules (n=44), interstitial lung diseases (n=20), pleural effusion (n=20), and empyema (n=19). Various indications included therapeutic or diagnostic procedures in bullous disease, mediastinal tumors, carcinoma, inflammatory lung disease, hyperhidrosis mani and bronchiectasis. Results: Mean drainage time was 6.0±4.7 days and hospital stay 8.4±6.6 days. One patient died on the ninth postoperative day after lobectomy for bronchial carcinoma due to cardiac failure, five patients needed a short period of reintubation due to acute respiratory failure. In two patients, thoracoscopic reoperation was necessary for closure of bronchopleural fistula. The self-reported questionnaire was returned by 173 (81%) of all patients within a mean follow-up of 18 (3–38) months. More than half of the patients (53%) reported no thoracic pain as early as 2 weeks after the procedure. At 2 weeks after the operation, 13% of patients suffered from localized pain and 31% from diffuse discomfort. Twelve percent needed pain medication regularly, and 3% occasionally. At 6 months postoperatively, three quarters of the patients had no complaints, 5% suffered from scar pain, and 20% had diffuse chest discomfort. One year after the procedure, 86% of the patients had no complaints, 9% suffered from minimal pain, and 5% from moderate pain. Two years after the procedure, 96% of the patients had no complaints at all. One hundred and twenty-five of the 140 patients (89%) working preoperatively went back to work within 2 weeks after the operation. Fifteen patients did not work between 3 and 16 weeks; 14 due to chest pain, one due to shoulder pain. Conclusion: Video-assisted thoracoscopy permits very early recovery with rapid reintegration into the working process. Long-term complaints after videothoracoscopy are rare.

Key Words: Minimally invasive surgery • Video-assisted thoracoscopy • Postoperative pain

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods... 3. Results 4. Discussion Appendix A. Conference... References

 
Since the modern era of thoracoscopic surgery in the early 1990s, video-assisted thoracoscopy (VATS) was proposed to be a less invasive approach than open procedures [1]. Today, it has become a useful and well-accepted adjunct to open procedures and has become the technique of first choice for many indications including biopsies [2], pleurectomies [1], sympathectomies [3] and various other disorders. Randomized [4,5] and non-randomized studies [6,7] have shown an improved course of early postoperative pain; however, results of pain, discomfort and cosmetic results in the long term are sparse.

The aim of this study was to assess early and long-term pain after VATS, time of incapacity for work, and patient satisfaction with scar cosmetics.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods... 3. Results 4. Discussion Appendix A. Conference... References

 
A retrospective study was carried out including a total of 213 consecutive patients (of whom 79 were female) who underwent thoracoscopic interventions for various thoracic diseases. Patients were identified by review of the charts and operation reports. Mean age was 48 (range 15–88) years. Main indications for operation were pneumothorax (n=70), pulmonary nodules (n=44), interstitial lung disease (n=20), pleural effusion (n=20) and empyema (n=19). Nine patients underwent bullectomy, six resection of a mediastinal tumor, another six had chronic pneumonia, and in five patients, an unexpected bronchial carcinoma was found. Five patients underwent thoracoscopic sympathectomy due to severe hyperhidrosis mani, four patients had bronchiectasis, and four patients were operated on for hematothorax. Rare indications were resection of metastasis (n=3), lung sequestration (n=2), bronchopleural fistula (n=2), epicardial dislocated pacer electrode (n=1), pericardial effusion (n=1) and a post-traumatic lung cyst (n=1).

Video-assisted thoracoscopy was performed under single-lung ventilation. Usually, patients were placed in lateral decubitus position with the upper arm suspended on a crossbar. Two to three 11.5-mm trocars were placed in the fifth to seventh intercostal space. Careful preoperative evaluation of the ideal intercostal spaces for assessment avoided torquing of the trocar which might play a key role in the development of chronic chest pain after thoracoscopy. In some cases, a 5.5-mm trocar was placed in the fourth intercostal space. A 10-mm, 25° angled thoracoscope coupled to a video system was used. At the end of the procedure, usually two chest tubes were inserted through the trocar incisions and connected to a closed chest tube drainage system with suction of -25 cmH₂O.

Most often, pleurectomies (n=59), wedge resections (n=52), pleurodesis (n=48) and biopsies were performed. In addition, 23 early and late decortications including hematothoraces, 22 bullectomies and 16 lobectomies were carried out. Various indications were thoracoscopic explorations with chest tube placement (n=9), bilateral sympathectomies (n=5), closure of bronchial fistula (n=2), extirpation of an epicardial pacer electrode (n=1), pericardial fenestration (n=1), thymectomy for treatment of myasthenia gravis (n=1) and resection of a post-traumatic lung cyst (n=1).

For assessment of the postoperative course of pain and other complaints like restriction in daily activity, a questionnaire was sent to all patients by mail. This self-reported form covered persistence, character and localization of postoperative pain, pain medication, and the ability to work and to perform daily activities. Additionally, patients who had complaints were invited for evaluation to the consulting hours.

	3. Results

Top Abstract 1. Introduction 2. Material and methods... 3. Results 4. Discussion Appendix A. Conference... References

 
One hundred and seventy-three (81%) of the patients with a mean follow-up time of 18.2 (range 3–38) months returned the questionnaire. Two weeks after the operation, more than half of the patients (53%; n=92) did not report any chest pain. Fifty-five patients (32%) had diffuse chest discomfort (20% minimal severity, 12% moderate severity), and 22 (13%) suffered from localized pain around the incisions (11% minimal pain, 2% moderate pain). This scar pain was found more often in cases were it was necessary to enlarge one of the incisions (i.e. lobectomies) with an incidence of 24%, as compared to 10% in the other cases. Four patients complained of pain in the whole hemithorax (one minimal, two moderate, one severe), and two patients felt pain in their shoulders (one minimal pain, one moderate pain). Therefore, only one patient out of 173 suffered from severe pain 2 weeks after the procedure (Table 1). This is confirmed by the fact that 147 patients (85%) did not use any specific pain medication as early as 2 weeks after the operation. Twenty-one patients (12%) needed pain medication regularly for a mean of 3.1±2.8 months, and five patients (3%) took drugs occasionally. No significant difference between pleural and parenchymal procedures regarding the incidence of diffuse chest pain (pleural 41% vs. parenchymal 29%) or localized pain at the incisions (pleural 10% vs. parenchymal 14%) was noted.

View larger version (14K): [in this window] [in a new window]   Fig. 1. Long-term incidence of postoperative pain in percentage of the whole study population. The straight line depicts decline in thoracic pain, the dotted line the course of localized scar pain.

Nearly 90% of the working persons (125 out of 140) reported back to work within 2 weeks after the operation (Fig. 2) . Fifteen patients did not work for an interval of 3 up to 16 weeks; 14 due to chest pain, and one due to shoulder pain. Twelve weeks after the operation, only one patient with shoulder pain was not able to work.

View larger version (12K): [in this window] [in a new window]   Fig. 2. Fitness for work. Of the 140 employed patients, 125 returned to work within 2 weeks after thoracoscopic operation.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods... 3. Results 4. Discussion Appendix A. Conference... References

The first known thoracoscopy was performed by H.C. Jacobaeus, a Swedish physician, in 1910, utilizing a cystoscope in order to free pleural adhesions in a patient with pulmonary tuberculosis to facilitate collapse therapy [8]. Indications for thoracoscopic surgery, however, remained rare until refinement of video technology has advanced in the early 1990s. It was proposed that thoracoscopy has the advantages of reduced thoracotomy-related morbidity, better cosmetic results, reduced pain, earlier postoperative mobilization, and even a shorter operation time in some indications.

It has been shown in several studies that in the early postoperative phase, thoracoscopy seems to induce less pain than thoracotomy. However, in most reports, long-term follow-up regarding chronic pain after thoracoscopic surgery has not been assessed. Additionally, information on the reintegration of the patients in the working process is lacking.

Giudicelli and coworkers [6] compared outcome of patients after lobectomy using either conventional thoracotomy or video-assisted minithoracotomy (5-cm cutaneous incision, 10-cm opening of costal space). Whereas operation time and postoperative pain were significantly lower in patients undergoing minimal invasive lobectomy, this had no effect on the impairment of lung function during the first week after the procedure, and no significant reduction of morbidity was noted. Pain-related morbidities like sputum retention and pneumonia showed a trend towards lower incidence in the group of patients who underwent thoracoscopic procedures. In contrast, Waller and colleagues presented a randomized comparison between thoracoscopic and conventional approaches for treatment of spontaneous pneumothorax were they found a significantly less impaired lung function on day 3 in thoracoscopically treated patients [4]. Postoperative pain was improved as compared to the open procedures despite the fact that 2-cm incisions for trocar insertion were used. These results were confirmed by Walker and colleagues [7], who performed thoracoscopic lobectomy combined with a short (7 cm) submammary incision without rib separation for specimen delivery. In comparison with open lobectomies, reduced postoperative pain resulting in less morphine consumption was noted. Furrer and coworkers [9] compared the course of pain and pulmonary function in patients undergoing posterolateral thoracotomy for lobectomy and patients who underwent thoracoscopic wedge resection. Santambrogio and colleagues [5] elucidated the role of thoracoscopy in the diagnosis of indeterminate solitary pulmonary nodules. They randomized 44 patients to either open or thoracoscopic approaches. Pain rated on a visual analog scale was significantly lower in patients operated on by video-assisted thoracoscopy. Additionally, operation time and hospital stay were significantly shorter.

Our non-controlled study population was heterogeneous with regard to age, physical abilities, and both indication and therapeutic approach. Therefore, comparison with other studies is of limited value. However, our results corroborate a rather low incidence of early postoperative pain with excellent therapeutic response to analgesic drug treatment, including epidural anesthesia, patient-controlled analgesia with opioids, and non-steroidal anti-inflammatory drugs.

Whereas these and other studies have shown that thoracoscopy leads to less pain in the early postoperative phase, it was questioned if there is any advantage in the long term. Prevalence of chronic pain was elucidated by Landreneau and coworkers in patients undergoing pulmonary resection either by thoracoscopy or thoracotomy [10]. They noted significantly lower levels of persistent pain in thoracoscopically operated patients within the first postoperative year, which was accompanied by less drug consumption. Also, a lower incidence of disturbed arm and shoulder function was observed after thoracoscopy. Our results point in the same direction, suggesting that thoracoscopy often leads to an earlier complete pain relief as compared to the same interventions performed with an open approach. However, randomized controlled studies cannot be performed any longer in this setting due to ethical reasons.

The underlying mechanisms causing less pain and facilitating fast recovery after thoracoscopy are not fully understood. It was suggested that a better preserved postsurgical immune function and decreased cytokine activation are at least partly responsible for the improved postoperative course as compared to open procedures. Recently, Gebhard and coworkers studied the influence of the open versus thoracoscopic approach on inflammatory response [11]. Patients with primary spontaneous pneumothorax were randomized to axillary thoracotomy or thoracoscopic procedures. The same stapling device for wedge resection was used in both groups, and apical pleurectomy was performed equally. C-Reactive protein and polymorphonuclear granulocyte elastase blood levels were significantly higher in patients undergoing open procedures. Moreover, prostanoids indicating either the endothelial damage of the lung (prostacyclin, thromboxane A₂) or pulmonary metabolic activity (prostaglandin M) were less elevated after thoracoscopic procedures. Therefore, the authors concluded that thoracoscopy not only reduces chest wall damage, but also minimizes lung impairment which might be due to less extensive manipulation.

The most impressive finding in our study was that nearly 90% of all the patients were able to return to work within 2 weeks after thoracoscopy. These data underline the impression that pain after thoracoscopic interventions is only mild to moderate in most patients.

Our results suggest that scar pain and satisfaction with the cosmetic results is improved after video-assisted thoracoscopy as compared to thoracotomy. In an earlier study, we found that after pleurectomy via thoracotomy for treatment of recurrent pneumothorax, nearly half of the patients suffered from scar pain, and 37% were not satisfied with scar cosmetics [12], whereas in this mixed study population, including patients who underwent more demanding procedures, only 13% had scar pain, and 96.5% are satisfied with the cosmetic result.

	Footnotes

 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Material and methods... 3. Results 4. Discussion Appendix A. Conference... References

 
Dr T. Rice (Cleveland, OH, USA): I would like to know how the questionnaire was constructed. You looked at 2 weeks, 6 months, 1 year and 2 years. Now, for this to be a correct study, obviously that will require four or five questionnaires to be mailed to each patient. Was that the way the study was constructed?

Dr Stammberger: No. This is one of the limitations of the study. It was one questionnaire which asked the first time 2 weeks after the operation, but then the patients were accessed on follow-up and asked, do you remember how long did you perceive any pain?

Dr Rice: I would object to your study and say it is only valid for the time that they are questioned, and to have them retrospectively tell you what kind of pain they had is really a big problem. So your study would only be valid if you can analyze it at the time of the question.

Dr Stammberger: At the end point?

Dr Rice: At the end point. And that is why I think your conclusions are a little suspect.

Dr Stammberger: I don't agree, because pain is something which you can't just move aside.

Dr Rice: I disagree completely. Further, in your paper some patients had malignant and some had benign disease?

Dr Stammberger: Yes.

Dr Rice: I think these studies are important but have flaws in their analysis.

Dr Stammberger: I also agree that a prospective study is needed, and at the moment we are just evaluating a new questionnaire which will be done the same way you proposed it.

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 are quite capable of remembering earlier pains.

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 gotten better at VATS, we have gotten better 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-F chest tubes. We use 24- or 20-F 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 Stammberger: The patients presented here present a time window from 3 years, so in this time we did not find any significant differences; however, since the very beginning we were very careful about choosing the trocar insertion ports so we could avoid torquing, and also in the initial stages we chose very small drainage tubes, about 20 or 24 F.

Dr J. 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.

	References

Top Abstract 1. Introduction 2. Material and methods... 3. Results 4. Discussion Appendix A. Conference... References

 

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2. Ferson P.F., Landreneau R.J. Thoracoscopic lung biopsy or open lung biopsy for interstitial lung disease. Chest Surg Clin N Am 1998;8:749-762.[Medline]
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10. Landreneau R.J., Mack M.J., Hazelrigg S.R., Naunheim K., Dowling R.D., Ritter P., Magee M.J., Nunchuck S., Keenan R.J., Ferson P.F. Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1994;107:1079-1085.[Abstract/Free Full Text]
11. Gebhard F.T., Becker H.P., Gerngross H., Bruckner U.B. Reduced inflammatory response in minimal invasive surgery of pneumothorax. Arch Surg 1996;131:1079-1082.[Abstract/Free Full Text]
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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ralph A. Schmid Walter Weder Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Stammberger, U. Articles by Weder, W. Search for Related Content PubMed PubMed Citation Articles by Stammberger, U. Articles by Weder, W.