The challenge of measuring post-operative pain reduction with opioid-sparing anesthetic techniques in video-assisted thoracoscopic surgery
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ABSTRACT:
SUBMITTER: Banks K
PROVIDER: S-EPMC9442525 | biostudies-literature | 2022 Aug
REPOSITORIES: biostudies-literature
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Project description:Pathology arising from the intrathoracic portion of the trachea (distal trachea), the carina and the main bronchi is usually neoplastic and is mainly treated with surgery. Resection of the intrathoracic portion of the trachea, the carina and the main bronchi for neoplastic lesions does not necessitate lung resection and is traditionally being conducted via open surgery. Video-assisted thoracic surgery (VATS) is witnessing an exponential growth and is the treatment of choice for early-stage non-small cell lung cancer (NSCLC). The experience accumulated over the past two decades along with the introduction of reliable and ergonomic technology, has led to the expansion of its indications. In this article we provide a detailed description of lung sparing distal tracheal, carinal and main bronchi resection for primary neoplasms of the airway, without involvement of the lung, with the uniportal video-assisted technique. The chest is entered through the fourth intercostal space, mid-axillary line. Dissection of the paratracheal space anteriorly, the tracheoesophageal groove posteriorly and the subcarinal space and division of the azygos arch are essential to mobilize the distal trachea and carina. Lateral dissection should be avoided beyond the points of division of the airway, as it may hinder the blood supply to the anastomosis. Any tension to the anastomosis should be relieved by release maneuvers. Ventilation is achieved through an endobronchial catheter, inserted into the left main bronchus through which a high-frequency jet ventilation catheter can be also inserted through it. The rationale of applying a minimally invasive technique for the conduction of tracheal and carinal resections, is to exploit its advantages, namely less pain, earlier mobilization and lower morbidity. Uniportal video-assisted resections of the distal trachea, carina and the main bronchi, are safe when conducted by experienced surgical and anesthetic teams.
| S-EPMC7656374 | biostudies-literature
Project description:BackgroundWe aimed to explore the impact of opioid-sparing anesthesia on patients' quality of recovery after video-assisted thoracoscopic surgery (VATS). We tested the primary hypothesis that our predefined opioid-sparing anesthesia provides better quality of patients' recovery compared to routine anesthesia in VATS.MethodsPatients between 18 and 70 years, scheduled for elective VATS, had an American Society of Anesthesiologists (ASA) class I-III under general anesthesia, were randomly allocated to: routine anesthesia group and opioid-sparing anesthesia group. Patients in the opioid-sparing anesthesia group were mainly given preoperative thoracic paravertebral blockade with intraoperative withholding longer acting opioids. Patients in routine anesthesia group received opioid-based anesthesia. The primary outcome was the Quality of Recovery-15 scale (QoR-15) at 6 hours after surgery. The secondary outcomes included QoR-15 at 24 and 48 hours after surgery, Overall Benefit of Analgesia Score Satisfaction with pain treatment (OBAS) and acute pain intensity at 6, 24 and 48 hours after surgery, and clinical outcomes of recovery after surgery.ResultsA total of 159 patients were included in final analysis. The median difference in QoR-15 between opioid-sparing anesthesia and routine anesthesia was 4 (95% CI: 1-6) at 6 hours, 8 (95% CI: 4-12) at 24 hours and 4.7 (95% CI: 1-6) at 48 hours after surgery respectively; 73.4% of patient showed good recovery in opioid-sparing anesthesia group, compared to 53.8% in routine anesthesia group at 24 hours after surgery (P=0.01). Patients demonstrated lower OBAS in opioid-sparing anesthesia group compared to routine anesthesia at all time points after surgery (P<0.05). The pain at most was significantly lower in opioid-sparing anesthesia group compared to routine anesthesia at 6 and 48 hours after surgery (P<0.05). Patients exhibited faster recovery with opioid-sparing anesthesia on time to mobilize and time to first flatus (P<0.01).ConclusionsOur intraoperative opioid-sparing anesthesia cannot improve patients' recovery at 6 hours after VATS lung surgery, but it demonstrates better outcomes at 24 hours after surgery compared to routine anesthesia, reaching to a clinically important difference.Trial registrationThis study is registered in the Chinese Clinical Trial Registry, ChiCTR2000031609.
| S-EPMC9344409 | biostudies-literature
Project description:BackgroundPatients undergoing video-assisted thoracoscopic surgery (VATS) have a lower risk of thrombosis compared to those undergoing open thoracotomy (OT) which may be due to several post-operative factors such as early mobilisation, shorter hospital stays, lower transfusion rates and lower risk of infections. Whether the higher thrombotic risk after OT is also linked to a peri-operative hypercoagulable state is a matter of debate. We therefore conducted a case-control study to compare peri-operative coagulation profiles in patients with primary lung cancer undergoing VATS vs OT.Materials and methodsAll consecutive patients undergoing VATS or OT for primary lung cancer at the Department of Thoracic Surgery of Padua University Hospital, Italy, between February and June 2018 were enrolled. Each patient provided a venous blood sample at least 30 min prior to surgical incision (T0) and 4±1 days after surgery (T1). Peri-operative coagulation profiles were assessed via traditional, viscoelastic whole blood (ROTEM® [Instrumentation Laboratory-Werfen]) and impedance aggregometry (Multiplate® Analyser [Roche Diagnostics]) tests.ResultsWe enrolled 65 patients (males 43, females 22; mean age 65±13 years) of whom 35 (54%) underwent VATS and 30 (46%) underwent OT. Compared to healthy controls, the surgical group (VATS and OT patients) had a significantly shorter clot formation time and higher alpha angle and maximum clot firmness values, as well as increased mean platelet function. In the post-operative period, patients who underwent OT had a significantly shorter clot formation time, higher alpha angle and maximum clot firmness values and higher mean platelet function vs VATS patients.DiscussionWhole blood ROTEM® profiles and Multiplate® aggregometry identified a more hypercoagulable post-operative state in patients who underwent OT than in those who underwent VATS. Larger studies are warranted to confirm our results and ascertain whether the observed hypercoagulability might promote post-operative thrombosis.
| S-EPMC7925226 | biostudies-literature
Project description:BackgroundUsing the non-intubated video-assisted thoracoscopic surgery (VATS) approach for small pulmonary nodules (SPNs) can accelerate patients' postoperative recovery. However, locating the SPNs intraoperatively by palpation can be difficult for thoracic surgeons. The advantages of using different preoperative positioning materials are different, especially for pulmonary-nodule-location-needle (P-N-L-N) and the microcoil. This retrospective study analyzed the advantages of two preoperative positioning techniques for VATS under non-intubation anesthesia.MethodsThe data were collected for a total of 150 patients with pulmonary nodules who underwent non-intubated VATS at the First People's Hospital of Yunnan Province from January 2018 to January 2021. The patients were divided into a preoperative positioning group (including a P-N-L-N group and microcoil group) and an unlocalized group. These included patients were all compliant with surgical guidelines and were suitable for preoperative localization. Their intraoperative and postoperative indicators were compared, and among these indicators, the operative time, number of postoperative drainage days, postoperative total drainage volume, postoperative discharge time was efficacy group and the intraoperative blood loss was safety group.ResultsPreoperative localization helped surgeons to explore nodules faster intraoperatively and remove SPNs precisely under non-intubated VATS. But the advantages of using different preoperative positioning materials are different. Positioning with either microcoil or P-N-L-N resulted in less operation time (P-N-L-N group: 94.90±28.42 min, microcoil group: 112.80±28.6 min, P<0.05), less intraoperative blood loss (P-N-L-N group: 35.80±21.17 mL, microcoil group: 75.00±65.22 mL, P<0.001) and less postoperative thoracic drainage volume (P-N-L-N group: 64.90±181.96 mL, microcoil group: 648.52±708.81 mL, P<0.001). However, the postoperative discharge time (P-N-L-N group: 5.02±1.35 days, microcoil group: 5.40±2.79 days, P=0.38) and postoperative drainage time(P-N-L-N group: 2.58±1.70 days, microcoil group: 3.18±2.49 days, P=0.16) was not statistically significant. Positioning with P-N-L-N seemed to have a better auxiliary effect for non-intubated VATS, suggesting its use can assist surgeons to determine the location of the lesion more accuracy intraoperatively. There was no significant difference in the pathological results among the groups.ConclusionsLocalization of SPNs is beneficial in non-intubated VATS, and the use of P-N-L-N was more effective than the microcoil in reducing operative time, intraoperative blood loss, postoperative total drainage volume, and postoperative discharge time.
| S-EPMC8902104 | biostudies-literature
Project description:BackgroundRobotic anatomic segmentectomy (RATS) for early-stage lung cancer is being increasingly performed in spite of limited published evidence. To evaluate its safety and oncologic efficacy, we compared the outcomes of both RATS and video-assisted thoracoscopic (VATS) segmentectomy in patients with small-sized (<2 cm) peripheral stage IA lung cancer.MethodsFrom November 2011 to January 2018, a total of 130 patients with resected stage IA non-small cell lung cancer (NSCLC) who underwent RATS (n=50) and VATS (n=80) pulmonary segmentectomy were included. Clinicopathologic data, recurrence rate, and survival were recorded.ResultsThe demographics, pulmonary function, comorbidity, and tumor size were similar between RATS segmentectomy and VATS segmentectomy. The surgery time, intensive care unit stay, hospital stay, and blood loss were reduced in the RATS group compared to the VATS group. The number of totally dissected lymph nodes and postoperative complications were similar between the 2 groups. There was no operative mortality. The intensity of narcotic use during hospital stay and the time to return to routine daily activities were also reduced in the RATS group. There was no recurrence observed in the RATS group during the median 38-month follow-up period; meanwhile, during a median 85-month follow-up period in the VATS group, local recurrence and distant recurrence was observed in 2 patients (2.5%) and 3 patients (3.75%) respectively. There was no significant difference in the 5-year recurrence-free survival between the RATS and VATS groups (100% vs. 93.75%; P>0.05).ConclusionsRATS can be performed safely and effectively in patients with early-stage NSCLC. The reduced narcotic use and earlier return to routine daily activities of RATS patients might reflect its less traumatic nature as compared to VATS. For stage IA disease with small tumors (<2 cm), segmentectomy performed by RATS has better oncologic efficacy when compared to VATS, although in this study, this difference did not reach statistical difference.
| S-EPMC7225141 | biostudies-literature
Project description:The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions.
| S-EPMC5639032 | biostudies-literature
Project description:ObjectivesLu's approach for video-assisted thoracoscopic surgery (LVATS), which derives from UVATS, is a novel surgical approach for VATS and carries out micro-innovation for lung cancer resection. The objective of this study is to elucidate the safety, feasibility, and efficacy of this novel surgical approach.MethodsThe clinical data of patients with non-small cell lung cancer (NSCLC) who underwent a curative thoracoscopic lobectomy between Mar. 2021 and Mar. 2022, were retrospectively collected, and analyzed. According to whether applied Lu's approach during the VATS operation, patients were divided into the LVATS group and the UVATS group. The propensity score (PS) matching method was used to reduce selection bias by creating two groups. After generating the PSs, 1:1 ratio and nearest-neighbor score matching was completed. Perioperative variables, including the operation time, intraoperative blood loss, lymph node stations dissected, total drainage volume, drainage duration, postoperative hospital stay, pain score (VAS, Visual Analogue Scale) on the postoperative first day (POD1) and third day (POD3), and incidence of postoperative complications, were compared between the two groups. The data were analyzed statistically with P<0.05 defined as statistically significant.ResultsA total of 182 patients were identified, among whom 86 patients underwent LVATS and 96 UVATS. Propensity matching produced 62 pairs in this retrospective study. There were no deaths during perioperative period. Patients in the LVATS group experienced a shorter operation time (88 (75, 106) VS 122 (97, 144)min, P <0.001), less intraoperative blood loss(20 (20, 30) VS 25 (20, 50)ml, P = 0.021), shorten incision length (2.50 (2.50, 2.50) VS 3.00 (3.00, 3.50)cm, P <0.001), and more drainage volume (460 (310, 660) VS 345 (225, 600)ml, P = 0.041) than patients in the UVATS group. There was not significant difference in the lymph node stations dissected(5 (4, 5) VS 5 (4, 5), P = 0.436), drainage duration (3 (3, 4) VS 3 (3, 4)days, P = 0.743), length of postoperative hospital stay (4 (4, 5) VS 4 (4, 6)days, P = 0.608), VAS on the POD1(4 (4, 4) VS 4 (4, 4), P = 0.058)and POD3 (3 (3, 4) VS 4 (3, 4), P = 0.219), and incidence of postoperative complications (P = 0.521) between the two groups.ConclusionsLu's approach is a safe and feasible approach for video-assisted thoracoscopic surgery for the lobectomy of NSCLC. This approach can shorten surgical time, reduce incision length and intraoperative blood loss.
| S-EPMC11198770 | biostudies-literature
Project description:BackgroundUniportal video-assisted thoracoscopic surgery (VATS) although considered less invasive than the multi-port techniques, is still an intercostal approach, resulting in intercostal nerve injury. Recently, some surgeons have tried to address this problem by attempting a subxiphoid approach. The aim of our study was to assess and compare results between intercostal and subxiphoid uniportal VATS lobectomy in terms of postoperative pain and quality of life (QoL).MethodsPatients from January 2014 to January 2018 undergoing subxiphoid and intercostal VATS lobectomy were prospectively assessed for pain and QoL at 1, 3, and 6 months following discharge. Postoperative pain was measured using a numeric rating scale (NRS) and QoL was assessed with the EuroQoL 5-dimension questionnaire (EQ5D).ResultsEight hundred and thirty-three patients undergoing lobectomy were included: 373 in the intercostal VATS group and 459 in the subxiphoid group. The proportion of patients with moderate or worse clinical pain was significantly lower at 1 and 3 months after subxiphoid VATS (P<0.01) compared with intercostal VATS. QoL was significantly higher following subxiphoid VATS at these same time points (P<0.001).ConclusionsUniportal subxiphoid VATS is a safe and feasible minimally invasive approach for undertaking pulmonary lobectomy that may result in reduced postoperative pain compared to conventional VATS. There may also be earlier return of QoL. A randomized controlled trial examining this further would provide further insight into our observations.
| S-EPMC7399408 | biostudies-literature
Project description:BackgroundReducing intra-operative opioid consumption benefits patients by decreasing postoperative opioid-related adverse events. We assessed whether opioid-free anesthesia would provide effective analgesia-antinociception monitored by analgesia index in video-assisted thoracoscopic surgery.MethodsPatients (ASA Ⅰ-Ⅱ, 18-65 years old, BMI <30 kg m-2) scheduled to undergo video-assisted thoracoscopic surgery under general anesthesia were randomly allocated into two groups to receive opioid-free anesthesia (group OFA) with dexmedetomidine, sevoflurane plus thoracic paravertebral blockade or opioid-based anesthesia (group OA) with remifentanil, sevoflurane, and thoracic paravertebral blockade. The primary outcome variable was pain intensity during the operation, assessed by the depth of analgesia using the pain threshold index with the multifunction combination monitor HXD‑I. Secondary outcomes included depth of sedation monitoring by wavelet index and blood glucose concentration achieved from blood gas.ResultsOne hundred patients were randomized; 3 patients were excluded due to discontinued intervention and 97 included in the final analysis. Intraoperative pain threshold index readings were not significantly different between group OFA and group OA from arriving operation room to extubation (P = 0.86), while the brain wavelet index readings in group OFA were notably lower than those in group OA from before general anesthesia induction to recovery of double lungs ventilation (P <0.001). After beginning of operation, the blood glucose levels in group OFA increased compared with baseline blood glucose values (P < 0.001). The recovery time and extubation time in group OFA were significantly longer than those in group OA (P <0.007).ConclusionsThis study suggested that our OFA regimen achieved equally effective intraoperative pain threshold index compared to OA in video-assisted thoracoscopic surgery. Depth of sedation was significantly deeper and blood glucose levels were higher with OFA. Study's limitations and strict inclusion criteria may limit the external validity of the study, suggesting the need of further randomized trials on the topic. Trial registration: ChiCTR1800019479, Title: "Opioid-free anesthesia in video-assisted thoracoscopic surgery lobectomy".
| S-EPMC8460000 | biostudies-literature
Project description: Not available
| S-EPMC11240445 | biostudies-literature