Eur J Cardiothorac Surg 2007;32:409-411. doi:10.1016/j.ejcts.2007.05.013
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved
Sequels 10 years after thoracoscopic procedures for benign disease
Jörg Hutter*,
Silvia Reich-Weinberger,
Wolfgang Hitzl,
Hubert J. Stein
Department of Surgery, Paracelsus Private Medical University, Müllnerhauptstr 48, 5020 Salzburg, Austria
Received 22 February 2007;
received in revised form 28 April 2007;
accepted 23 May 2007.
* Corresponding author. Tel.: +43 662 4482 57358; fax: +43 662 4482 51008. (Email: j.hutter{at}salk.at).
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Abstract
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Objective: Video-assisted thoracic surgery (VATS) is recognized to be as effective as open thoracic surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity. Chronic postoperative pain (CPP) is defined as persisting more than 2 months after the procedure. CPP and other neurological sensations like dysesthesia or numbness are found frequently, but little is known about the outcome of those patients many years after the primary procedure. Methods: In 1999 we retrospectively investigated a group of 46 (31.9%) out of 144 patients who were identified with sequels at a mean of 32 months after a VATS procedure. Now at 123 months postoperation we reinvestigated those patients for ongoing sequels. Results: Out of 46 patients, 36 were still alive and could be reached for an interview. Eighteen patients (50%) were now free from symptoms while 18 patients (50%) still suffered from sequels. From the group of 144 patients operated on, sequels were now present in 18 patients (12.5% at 123 months vs 31.4% at 32 months, p
= 0.0002). Pain was present in 17 patients (11.8% vs 20.1%, p
= 0.11), in 3 patients (2.1% vs 18.1%, p
< 0.000001) even at rest, and in 4 patients (2.7% vs 12.5%, p
= 0.0002) only at exercise. Ten patients (6.9% vs 28.5%, p
= 0.096) suffered from pain occasionally, e.g. because of changing weather. Painkillers were taken only by one patient (0.7% vs 16.6%, p
< 0.0001) occasionally, and the sequels impacted the life of one female patient (0.7% vs 13.2%, p
< 0.0001) badly. Numbness was present in 16.9% versus 1.3% (p
= 0.0013) of patients. Conclusion: Early postoperative sequels are frequently found in VATS procedures, but patients with pain even after years have a nearly 50% chance to eliminate their problems. In addition, numbness and dysesthesia seem to disappear almost completely several years after the procedure.
Key Words: Chronic pain • VATS • Benign pulmonary disease
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1. Introduction
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Video-assisted thoracic surgery (VATS) is recognized to be as effective as open surgery for a variety of diagnostic and therapeutic conditions, but with significantly less morbidity [1]. Reports in the literature find a prevalence of chronic pain in 5–33% [2–8] of patients undergoing thoracoscopic procedures. Numbness and paresthesia are rarely reported in the literature but are present in up to 10% of patients 1 year after a thoracoscopic procedure [2,9]. It is known that numbness and dysesthesia may decrease by time, but long-term results are not known.
In 1999 we investigated a series of 144 patients undergoing various thoracoscopic procedures for benign disease [9]. In this series we found 46 patients (31.9%) suffering from chronic sequels at a mean of 32 months postoperatively. This group of patients was now reinvestigated to assess their sequels at a mean interval of 123 months.
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2. Methods
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Between 1993 and 1998 a series of 161 patients underwent a thoracoscopic procedure for benign disease and were not converted to an open thoracotomy procedure. Patients with malignant disease were excluded to avoid pain due to tumor recurrence. Out of 144 patients who were eligible for the final evaluation, at a mean of 32 months (mo) 46 patients (31.9%) suffered from chronic sequels.
To re-evaluate the sequels, all 46 patients were interviewed by either telephone or mail at a mean of 123 (89–159) mo postoperatively. Thirty patients were male and 16 were female, with a mean age of 53 (29–75) years. Thirty-six (78.3%) of the 46 patients suffering from sequels at 32 mo could be reached for an interview. Six patients were already deceased and four patients could not be reached by either telephone or mail.
Primary indications for the procedure in sequel patients were pneumothorax in 14, empyema in 11, interstitial lung disease in 1, tuberculoma in 1, pleural effusion in 2, hamartoma in 2, and others in 4 patients.
The following parameters were investigated using a questionnaire sent by mail or telephone: sequels (generally) and, if yes, then pain, dysesthesia, numbness; regular use of painkillers; if bothered in the daily life activity by the sequels; and ability to work. The following factors were checked for significance for chronic sequels: age, sex, number of drains used, use of stapling devices, and length of drainage. The use of stapling devices was additionally checked for significance for chronic pain, numbness, and dysesthesia. The results were compared between 1999 and 2006 and checked for significance.
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3. Statistical methods
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Univariate analyses using the test of McNemar were used to analyze the 2 x 2 cross tabulation tables. A p-value less than 5% was considered as statistically significant. All analyses were done with StatXact (Cytel Software Corporation, Cambridge, MA) and STATISTICA 6.1 (Hill T, Lewicki P. STATISTICS Methods and Applications. StatSoft, Tulsa, OK, 2006).
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4. Results
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After a mean of 123 mo 36 patients could be re-evaluated. Eighteen patients (50%) were free from former symptoms, while sequels were still present in 18 patients (50%).
From the originally investigated group of 144 patients sequels were present in 18 patients (12.5% at 123 mo vs 31.9% at 32 mo) undergoing a thoracoscopic procedure for benign disease (Table 1
).
Seventeen (12.5% vs 20.1%, p
= 0.11) of the 144 patients were suffering from pain, 10 patients (6.9% vs 28.5%, p
= 0.096) only occasionally, e.g. with changing weather. Pain was present during exercise in four patients (2.7% vs 12.5%, p
= 0.0002) and at rest in three patients (2.1% vs 18.1%, p
< 0.000001). Only one patient (0.7% vs 16.6%, p
< 0.0001) needed pain medication occasionally and one female patient was suffering from pain impacting her daily life badly (0.7% vs 13.2%, p
< 0.0001). All patients were able to work despite their sequels (0% vs 6.3%).
Two patients complained about numbness (1.3% vs 16.9%, p
= 0.0013) including one patient suffering from numbness and pain. No patient suffered from dysesthesia (0% vs 8.3%, significance not tested). Between 1999 and 2006 there was also a significant decrease of chronic sequels in patients where two drains instead of one were used and where staplers were used for resection.
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5. Discussion
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Chronic sequels are adverse side effects in any operation and very common in general thoracic surgery [11,12]. The most obvious advantages of the thoracoscopic approach to pulmonary surgery are the reduction of postoperative complications and an earlier improved pulmonary function. There are numerous studies demonstrating the advantages concerning pain in the early postoperative course [2,3,5,6] but only a few studies addressing the impact of VATS on chronic pain and other sequels [8,9].
A primary goal of minimally invasive surgery is the reduction in pain-related operative morbidity associated with classic open thoracic surgical techniques [13]. VATS is accepted as reducing acute postoperative pain and analgesic requirements compared to both muscle-sparing and standard thoracotomy [13].
However, comparative studies have shown that there is no difference in chronic postoperative pain (CPP) occurrence between VATS and open thoracotomy [14,3]. In one large study, there was less pain in the VATS group up to 1 year postoperation, but the incidence of pain after 1 year was identical [3]. An incidence of CPP of 31.7% was present in 60 patients undergoing VATS pleurectomy for spontaneous pneumothorax [7].
The mechanism of chronic sequels after thoracic procedures are not fully understood because of numerous causal factors like nerve damage, rib fracture, overextension of the costotransverse joint or recurrence of a primary cancer [14]. In VATS procedures the mechanisms for chronic pain were described early by Landreneau et al. [13] as direct damage to the nerves by ports or rib fracture due to forced maneuvers in the intercostal space, but no study ever proved this to be true. Jutlay et al. [15] found a lower prevalence of postoperative pain and residual paresthesia using a uniportal versus a standard three-port technique in patients undergoing VATS for pneumothorax, anticipating a uniportal access will predispose to a lower incidence of neurological symptoms. Recently Maguire et al. [16] published a paper presenting data on the prevalence of the nerve damage during open thoracic surgery and its association with chronic pain and explored the intraoperative factors that may influence nerve damage and chronic pain.
They showed in an open thoracotomy group of patients that intraoperative nerve damage demonstrated by recorded muscle-evoked potentials did not correlate with chronic postoperative pain and/or cutaneous sensations at 3 months postoperatively. This suggests that either the amount of intraoperative nerve damage is not indicative of long-term nerve damage or there is a more significant cause for chronic pain than intercostal nerve injury. Owing to the lack of similar studies in VATS patients we cannot draw final conclusions for patients undergoing a VATS procedure.
Why symptoms in patients disappear could by explained by the recovery of a damaged nerve. Different patterns of nerve lesions are described in the Seddon's classification [17]. The damage of a nerve can be either incomplete (neurapraxia and axonotmesis) or complete (neurotmesis). Neurapraxia is a segmental demyelinization caused by pressure on the nerve and a recovery is expected from days to weeks. Axonotmesis is a segmental demyelinization with a disruption of the axon. In this situation a recovery is likely in months with defect healing. In a neurotmesis with a complete discontinuation of the nerve a recovery is unlikely. In cases of neuropathic pain a recovery is unlikely [18], and therefore, early recognition and aggressive management is critical to successful outcome.
The key message of this study is that in patients with chronic sequels there is a chance of 50% with a significant difference that their problem will be eliminated in the long term. A significant reduction of pain at rest and at exercise as well as the need of painkillers and the impact of sequels on the daily life could be found. There was no significant change of pain in situations like changing weather. There was not a single patient in which a switch from one sequel to another was noted (e.g. pain to numbness or vice versa). A major drawback of our study is the loss of 10 patients to follow up. Six patients were already deceased and the remaining four were suffering from numbness in the previous study [9]. Assuming that pain is more debilitating and has more impact on daily life the message of our study is not shortened by this drawback.
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Acknowledgments
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The authors thank Mr Jim Johnson from Chattanooga Tennessee for proofreading the manuscript.
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Abstract
1. Introduction
