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Eur J Cardiothorac Surg 2003;23:390-396
© 2003 Elsevier Science NL

The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy

Wilson W.L. Lia, Rosanna L.M. Leeb, T.W. Leea, Calvin S.H. Nga, Alan D.L. Sihoea, Innes Y.P. Wana, Ahmed A. Arifia, Anthony P.C. Yima*

a Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China
b Department of Physiotherapy, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong SAR, China

Received 15 August 2002; received in revised form 22 November 2002; accepted 25 November 2002.

* Corresponding author. Tel.: +86-852-2632-2629; fax: +86-852-2647-8273
e-mail: yimap{at}cuhk.edu.hk


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. ASES activities...
 References
 
Objective: Whether video-assisted thoracic surgery (VATS) is associated with less shoulder dysfunction when compared with posterolateral thoracotomy (PLT) remains unclear. We therefore conducted this prospective study to assess the shoulder function in patients following major lung resection using either the VATS or PLT approach. Methods: Twenty-nine consecutive patients were prospectively recruited into the study. Eighteen patients underwent major lung resection through VATS (VATS group) and 11 patients through PLT (open group). Shoulder function was measured preoperatively, and postoperatively at 1 week, 1 month and at 3 months. All assessments were done by two experienced physiotherapists using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form. Results: Shoulder strength was significantly better preserved in the VATS group at 1 week after surgery when compared with the PLT group (92 versus 81% of preoperative value; P=0.024). VATS patients also had better range of motion especially with respect to external rotation at 1 week (98 versus 91%; P=0.015) and forward elevation at 1 month (98 versus 93%; P=0.024) and 3 months after surgery (100 versus 96%; P=0.021). Analgesic requirement was significantly less in the VATS group postoperatively at 1 week (P=0.009) and 1 month (P=0.004). Conclusions: VATS major lung resection is associated with significantly less shoulder dysfunction and pain medication requirement in the early postoperative period when compared to the PLT approach.

Key Words: Video-assisted thoracic surgery • Thoracotomy • Shoulder function


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. ASES activities...
 References
 
Posterolateral thoracotomy (PLT) has long been the standard surgical approach for most thoracic procedures [1]. This incision provides excellent access to the chest cavity, but often requires the division of several major chest wall muscles and spreading of the ribs. Experience has shown that this approach may lead to serious postoperative morbidity like chronic pain, compromised pulmonary function and restriction of shoulder function [1]. With the introduction of minimal access techniques, these thoracic procedures can now also be performed through video-assisted thoracic surgery (VATS) [2].

The fact that access trauma is reduced with VATS has been well documented. There is general consensus on the benefits of this approach with respect to less postoperative pain [3,4], better preservation of pulmonary function [4–6] and earlier return to normal activities [7]. However, whether VATS is associated with less shoulder dysfunction remains to be defined. Adequate functioning of the shoulder is essential for performing various basic activities of daily living [8], and postoperative shoulder dysfunction could become a serious long-term disability. We therefore conducted this study to assess the shoulder function in patients after major lung resection following either VATS or PLT.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 Appendix A. ASES activities...
 References
 
2.1. Patients
From April 2001 to October 2001, 29 consecutive patients who underwent major lung resection for various thoracic diseases were prospectively recruited into the study. Patients with known shoulder injury, tumor invasion into the chest wall or brachial plexus were beforehand excluded. As a result, 18 patients underwent VATS major lung resection (VATS group) and 11 patients underwent resection through PLT (open group).

2.2. Operative technique
VATS resection was carried out whenever technically advisable. This was the case whenever there were complete or near complete fissures, with minimal or no pleural adhesions. Our technique for VATS major lung resections has been described in detail elsewhere [9]. We emphasize on avoiding rib spreading and torquing of the thoracoscope at all times [10]. Patients who were considered not suitable for VATS underwent the conventional posterolateral thoracotomy, with division of the latissimus dorsi and serratus anterior muscles.

2.3. Shoulder function assessment
Shoulder function assessments were done preoperatively, and postoperatively at 1 week, 1 month and at 3 months after surgery. All patients received chest physiotherapy and were encouraged to mobilize starting from postoperative day 1. Shoulder function was measured following the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form [11]. This is a standardized form containing an assessment section to evaluate shoulder strength, shoulder range of motion, specific physical signs and shoulder stability, and a patient self-evaluation section with a visual analog scale (VAS) pain assessment, a VAS instability assessment and an activities of daily living (ADL) questionnaire (Appendix A). For the current study, only shoulder strength, active shoulder range of motion, VAS pain score and ADL questionnaire assessments were deemed relevant and were used for data analysis. All assessments were done by two experienced physiotherapists.

2.3.1. Shoulder strength
Shoulder strength was measured in forward elevation, abduction, external rotation and internal rotation. Strength of each movement was graded on a scale from 0 to 5, with 0 representing no contraction and 5 equaling normal strength. These scores were combined for a total assessment of shoulder strength.

2.3.2. Shoulder range of motion
Active shoulder range of motion was assessed in forward elevation, external rotation with arm at side, external rotation with arm at 90° abduction, internal rotation and cross-body adduction. Forward elevation, external rotation with arm at side and external rotation with arm at 90° abduction were measured with a goniometer in degrees. Internal rotation was estimated by noting the highest segment of the posterior spinal anatomy reached with the thumb. Cross-body adduction was assessed by measuring the distance (in centimeter) of the antecubital fossa from the opposite acromion.

2.3.3. Pain and analgesic requirement
Patients were asked whether they had pain on the side of their surgical procedure. The severity of pain was graded on a 0–10 visual analog scale, with 0 points for no pain to 10 points for pain as bad as it can be. Furthermore, the patients were asked whether they took pain medication. In general, dologesic (containing dextropropoxyphene HCl 32.5 mg and paracetemol 325 mg) was administered for postoperative pain control, and the number of tablets required daily on average was recorded.

2.3.4. ADL questionnaire
The ADL questionnaire contains ten questions regarding various activities of daily living (Appendix A). These are scored on a four point ordinal scale from 0 to 3 points, where 0 stands for unable to do and 3 equals not difficult to do. A cumulative ADL status score is derived by adding up the scores for all ten questions.

2.3.5. ASES shoulder score index
The patient self-evaluation section results in an ASES Shoulder Score Index and is derived from the VAS pain assessment and ADL questionnaire. The VAS pain score is subtracted from 10 and the resulting number is multiplied by 5 for a maximum of 50 points. The cumulative ADL score is multiplied by 5/3 for a maximum of 50 points. This results in a maximum possible ASES Shoulder Score Index of 100 points. High scores stand for high functionality.

2.4. Statistical analysis
Statistical analysis was performed using the Statistical Package for Social Sciences for Windows version 10.0.0 (SPSS/PC for Windows ver. 10.0.0). Postoperative changes in shoulder strength, shoulder range of motion, ADL status and ASES Shoulder Score Index are expressed as a percentage of the patient's preoperative baseline assessment. Continuous data was analyzed using the unpaired Student's t-test. Frequencies were compared using {chi}2-test; if a frequency in at least one cell of the table is less than 5, the Fisher's Exact Test was computed instead. P-values less than 0.05 were considered statistically significant.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 Appendix A. ASES activities...
 References
 
A total of 29 patients were recruited into the study, with 18 patients undergoing major lung resection through VATS (VATS group) and 11 patients through PLT (open group). No significant differences were found between the two groups regarding gender, age, nature of the operation and pathological results (Table 1). Furthermore, there were no significant differences regarding their preoperative shoulder function (Table 2).


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  		Table 1. Patient characteristics and surgical data

 

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  		Table 2. Preoperative baseline shoulder function assessment

 
Shoulder function evaluations were performed only after all chest drains have been removed. There was no significant difference between chest drainage duration between groups. One VATS patient had prolonged air leak postoperatively, and subsequently missed her 1 week assessment. Data on all postoperative shoulder assessments are shown in Table 3.


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  		Table 3. Postoperative shoulder function assessments

 
It was clear that VATS patients had superior shoulder strength throughout the whole follow-up period when compared with patients who had a PLT, with significant differences found at 1 week after surgery (Fig. 1) . Furthermore, VATS patients also had significantly better postoperative shoulder range of motion (Figs. 2A–C) . Although both groups had significantly worse shoulder range of motion after their operation, the decline in range of motion was significantly less in the VATS patients regarding external rotation with arm at 90° abduction postoperatively at 1 week (Fig. 2C). In addition, at 1 and 3 months after surgery, VATS patients had significantly better shoulder range of motion regarding forward elevation (Fig. 2A).



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  		Fig. 1. Postoperative changes in shoulder strength in patients undergoing major lung resection through VATS versus posterolateral thoracotomy (open). (*P<0.05).

 


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  		Fig. 2. Postoperative changes in shoulder range of motion regarding forward elevation (A), external rotation with arm at side (B) and external rotation with at 90° abduction in patients undergoing major lung resection through VATS versus posterolateral thoracotomy (open). (*P<0.05).

 
At the same time, patients in the VATS group experienced less postoperative pain, reflected by the lower requirement of analgesics after surgery. Significant differences were found regarding the amount of pain medication consumption between the two groups postoperatively at 1 week and 1 month (Fig. 3A) . Significantly fewer patients from the VATS group took any pain medication at all 1 month after surgery. Furthermore, there was a trend for VATS patients to exhibit lower VAS pain scores (Fig. 3B). VATS patients also tended to have better ADL status than patients from the open group (Fig. 4) . However, neither the differences in cumulative ADL score nor the results of the separate questions of the ADL questionnaire reached statistical significance. Likewise, a similar trend was found for VATS patients to have higher ASES Shoulder Score Index (Fig. 5) . Again, this was not statistically significant.



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  		Fig. 3. Postoperative analgesic requirement (A); and pain scores (B) in patients undergoing major lung resection through VATS versus posterolateral thoracotomy (open). Postoperative analgesic requirement is expressed as the number of tablets dologesic (dextropropoxyphene HCl 32.5 mg and paracetemol 325 mg) required on average daily. (*P<0.05).

 


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  		Fig. 4. Postoperative changes in ADL status in patients undergoing major lung resection through VATS versus posterolateral thoracotomy (open).

 


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  		Fig. 5. Postoperative changes in ASES shoulder score index in patients undergoing major lung resection through VATS versus posterolateral thoracotomy (open).

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
Appendix A. ASES activities...
 References
 
The results of this prospective study suggest that VATS is associated with short-term benefits regarding shoulder function and pain for performing major lung resections when compared with posterolateral thoracotomy. Significant benefits for the VATS group were found postoperatively at 1 week regarding shoulder strength, and at 1 week, 1 month and 3 months regarding shoulder range of motion. At the same time, VATS patients required significantly less pain medication postoperatively at 1 week and 1 month.

Corresponding with their significantly better shoulder function after surgery, a consistent trend was found for VATS patients to have higher levels of ADL status throughout the follow-up period. This was eagerly anticipated, because adequate shoulder function is a basic requirement for various areas of daily functioning [8]. However, due to the small number of patients, this trend was not statistically significant. Likewise, the ASES Shoulder Score Index, which is a combination of the ADL questionnaire and VAS pain assessment, did not reveal significant differences either.

Our findings seem to be consistent with previously reported studies. Landreneau et al. [12] estimated shoulder function in patients comparing VATS with limited lateral thoracotomy by measuring the strength of the latissimus dorsi and serratus anterior muscle groups with a standard dynamonometer. In a later study, Landreneau et al. [13] used self-developed questionnaires to assess shoulder restriction in a similar group of patients. In both studies, VATS was associated with less short-term shoulder dysfunction, although there were no significant differences between the two groups 1 year after surgery.

We acknowledge that our present study has several limitations. Although the investigation was of prospective nature, randomization of the patients was not performed. Furthermore, blinding of the assessors was not practical because the shoulder function assessments required patients to undress, revealing the length of the scar and the nature of the operation. Moreover, our findings are limited by the small sample size. The shoulder function assessments were fairly time-consuming, and its labor-intensiveness restricted us from recruiting more patients and extending the follow-up period.

Functional limitations of the shoulder are difficult to assess due to significant overlap with pain. The relationship between shoulder dysfunction and pain is complex, and it is unclear to what extent the differences in postoperative pain have contributed to the differences in postoperative shoulder function. Furthermore, it remains largely indistinguishable what part of the shoulder dysfunction is contributed by the division of major chest wall muscles, and what part is due to rib-spreading. It is generally believed although not vigorously, scientifically proven that the morbidity of a thoracotomy is mainly the result of rib spreading rather than muscle division. Various authors have reported that shoulder function in the early postoperative period is better preserved after muscle-sparing thoracotomy when compared with posterolateral thoracotomy [1,14,15]. The consistent difference between these two approaches is the preservation of the latissimus dorsi (with or without preservation of the serratus anterior) in the muscle-sparing thoracotomy, while location, length of incision and amount of rib-spreading remain similar. This suggests that division of major chest wall muscles is an important factor contributing to postoperative shoulder dysfunction. In contrast, differences between VATS and muscle-sparing thoracotomy include not only the length of the incision, but more importantly, the avoidance of rib-spreading. There has been no published report so far on a study comparing VATS with muscle-sparing thoracotomy with respect to shoulder function. Nevertheless, studies comparing VATS with lateral thoracotomy (with or without muscle sparing) showed that the former is associated with less short term shoulder dysfunction [12,13], suggesting that rib-spreading does play an essential role in causing postoperative shoulder dysfunction. However, the precise contribution from each of these factors remains to be further investigated.

Recent publications have suggested that exercise training could play an important role in the postoperative rehabilitation of the patient [16,17]. Specifically with upper extremity exercise modalities, improvement in shoulder strength and function can be expected. Furthermore, it is suggested that exercise training can lead to improvement in the ability to perform activities of daily living, exercise endurance, pulmonary function and quality of life [16,17]. It would be reasonable to assume, although not scientifically proven that patients with less early postoperative discomfort are able to comply better with, and derive more benefit from such exercise training.

In conclusion, despite the mentioned limitations and small number of patients, our study showed that the VATS approach is associated with better preservation of shoulder function and lower analgesics requirement in the early postoperative period when compared with the standard open approach.


   Acknowledgments
 
We are indebted to Herman Lau from the Department of Physiotherapy for his support and contribution to the study.


   Footnotes
 
Presented at the 16th Annual Meeting of the European Association for Cardio-thoracic Surgery, Monte Carlo, Monaco, September 22–25, 2002.


   Appendix A. ASES activities of daily living questionnaire [11]
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. ASES activities...
References
 
Indicate your ability to do the following activities: (0=Unable to do; 1=Very difficult to do; 2=Somewhat difficult; 3=Not difficult)

1. Put on a coat
0 1 2 3

2. Sleep on your painful or affected side
0 1 2 3

3. Wash back/do up bra in back
0 1 2 3

4. Manage toileting
0 1 2 3

5. Comb hair
0 1 2 3

6. Reach a high shelf
0 1 2 3

7. Lift 10 lbs above shoulder
0 1 2 3

8. Throw a ball overhand
0 1 2 3

9. Do usual work
0 1 2 3

10. Do usual sport
0 1 2 3


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 Appendix A. ASES activities...
 References
 

  1. Hazelrigg S.R., Landreneau R.J., Boley T.M., Priesmeyer M., Schmaltz R.A., Nawarawong W., Johnson J.A., Walls J.T., Curtis J.J. The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain. J Thorac Cardiovasc Surg 1991;101:394-401.[Abstract]
  2. Yim A.P., Lee T.W., Izzat M.B., Wan S. Place of video-thoracoscopy in thoracic surgical practice. World J Surg 2001;25:157-161.[CrossRef][Medline]
  3. Giudicelli R., Thomas P., Lonjon T., Ragni J., Morati N., Ottomani R., Fuentes P.A., Shennib H., Noirclerc M. Video-assisted minithoracotomy versus muscle-sparing thoracotomy for performing lobectomy. Ann Thorac Surg 1994;58:712-718.[Abstract]
  4. Nagahiro I., Andou A., Aoe M., Sano Y., Date H., Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72:362-365.[Abstract/Free Full Text]
  5. Nakata M., Saeki H., Yokoyama N., Kurita A., Takiyama W., Takashima S. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 2000;70:938-941.[Abstract/Free Full Text]
  6. Kaseda S., Aoki T., Hangai N., Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy. Ann Thorac Surg 2000;70:1644-1646.[Abstract/Free Full Text]
  7. Sugiura H., Morikawa T., Kaji M., Sasamura Y., Kondo S., Katoh H. Long-term benefits for the quality of life after video-assisted thoracoscopic lobectomy in patients with lung cancer. Surg Laparosc Endosc Percutan Tech 1999;9:403-408.[CrossRef][Medline]
  8. Triffitt P.D. The relationship between motion of the shoulder and the stated ability to perform activities of daily living. J Bone Joint Surg Am 1998;80:41-46.[Abstract/Free Full Text]
  9. Yim A.P., Izzat M.B., Liu H.P., Ma C.C. Thoracoscopic major lung resections: an Asian perspective. Semin Thorac Cardiovasc Surg 1998;10:326-331.[Medline]
  10. Yim A.P.C. Minimizing chest wall trauma in video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1995;109:1255-1256.[Free Full Text]
  11. Richards R.R., An K.N., Bigliani L.U., Friedmann R.J., Gartsmann G.M., Gristina A.G., Ianotti J.P., Mow V.C., Sidles J.A., Zuckermann J.D. A standardized method for the assessment of shoulder function. J Shoulder Elbow Surg 1994;3:347-352.
  12. Landreneau R.J., Hazelrigg S.R., Mack M.J., Dowling R.D., Burke D., Gavlick J., Perrino M.K., Ritter P.S., Bowers C.M., DeFino J. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285-1289.[Abstract]
  13. 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;107:1079-1086.[Abstract/Free Full Text]
  14. Khan I.H., McManus K.G., McCraith A., McGuigan J.A. Muscle sparing thoracotomy: a biomechanical analysis confirms preservation of muscle strength but no improvement in wound discomfort. Eur J Cardiothorac Surg 2000;18:656-661.[Abstract/Free Full Text]
  15. Kutlu C.A., Akin H., Olcmen A., Biliciler U., Kayserilioglu A., Olcmen M. Shoulder-girdle strength after standard and lateral muscle-sparing thoracotomy. Thorac Cardiovasc Surg 2001;49:112-114.[Medline]
  16. ACCP/AACVPR Pulmonary Rehabilitation Guidelines Panel. American College of Chest Physicians. American Association of Cardiovascular and Pulmonary Rehabilitation. Pulmonary rehabilitation: joint ACCP/AACVPR evidence-based guidelines. Chest 1997;112:1363-1396.[Free Full Text]
  17. British Thoracic Society. Pulmonary rehabilitation. Thorax 2001;56:827-834.[Free Full Text]



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