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PubMed2004

Comparison of closed-tube thoracostomy and open thoracotomy procedures in the management of thoracic empyema in childhood.

PURPOSE: There is still an argument concerning the correct management of pleural empyema. The aim of this study is to compare the effectiveness of closed-tube thoracostomy and open thoracotomy procedures in the management of empyema in children. METHODS: This is a prospective study of 30 patients with parapneumonic empyema who were managed randomly either by closed-tube thoracostomy or open thoracotomy procedures. The two procedures were compared based on the respective times to achieving normal body temperature and breath rates, duration of tube drainage, length of hospitalization, and complication rates. Both groups were also assessed by comparing tube drainage duration, pleural fluid pH, agent pathogen and glucose level. RESULTS: Average tube duration was 7.5 +/- 1.1 days and average hospital stay was 9.5 +/- 1.5 days in the open thoracotomy group. In the closed tube thoracostomy group tube, duration was 13.8 +/- 2.3 days and average hospital stay 15.4 +/- 2.3 days. In the open thoracotomy group 73.3% of the patients had achieved normal body temperature and 66.7 % had a normal breath rate within the first 48 hours. In the closed tube thoracostomy group these rates were 40% and 20%, respectively. In both groups, tube drainage duration was found to be longer in patients whose pleural fluid pH was < 7.2. CONCLUSION: The authors conclude that open thoracotomy is a safe, efficient, and easy method of treatment for pleural empyema in children. It was also observed that pleural fluid pH level is the most important prognostic criteria in pleural empyema.

Child↗
PubMed1987

Collateral blood flow after coronary occlusion: influence of barbiturate anaesthesia and thoracotomy.

A study was undertaken to determine whether barbiturate anaesthesia, with or without thoracotomy, adversely affects collateral blood flow during acute coronary artery occlusion. Twelve dogs were instrumented with an electromagnetic flow probe and pneumatic occluder on the left circumflex artery; seven days later, in the conscious state, complete coronary artery occlusion was induced for 8 min. Heart rate, mean aortic pressure, and subendocardial and subepicardial blood flow in the ischaemic zone were measured by radioactive microspheres before and 5 min into coronary artery occlusion. Measurements were repeated after pentobarbital 30 mg.kg-1 (n = 7) and after pentobarbital plus thoracotomy (n = 12). Compared with the conscious state, pentobarbital and thoracotomy produced a decrease in endocardial blood flow in the ischaemic zone (0.21(0.04) to 0.15(0.03) ml.min-1.g-1) and a modest redistribution from endocardium to epicardium (ratio of endocardial to epicardial flow 0.55(0.06) to 0.49(0.07) ml.min-1.g-1), coincident with an increase in heart rate from 127 to 178 beats.min-1 but no change in mean arterial pressure. Directionally similar, but smaller, changes occurred during anaesthesia without thoracotomy. To determine the role of tachycardia five of the animals were studied in the conscious state during a 50% increase in heart rate induced by atrial pacing. A similar decrease occurred in coronary blood flows as with anaesthesia. The results indicate that barbiturate anaesthesia and thoracotomy produce a diminution in collateral flow to ischaemic myocardium, together with an accentuation of its transmural maldistribution, and suggest that anaesthetic induced tachycardia is primarily responsible for these flow alterations.

Anesthesia, Intravenous↗
PubMed2006

Acupuncture is a feasible treatment for post-thoracotomy pain: results of a prospective pilot trial.

BACKGROUND: Thoracotomy is associated with severe pain that may persist for years. Acupuncture is a complementary therapy with a proven role in pain control. A randomized trial showed that acupuncture was effective in controlling pain after abdominal surgery, but the efficacy of this technique for the treatment of thoracotomy pain has not been established. We developed a novel technique for convenient application of acupuncture to patients undergoing thoracotomy, and in a Phase II trial evaluated the safety of this intervention and the feasibility of doing a randomized trial. METHODS: Adult patients scheduled for unilateral thoracotomy with preoperative epidural catheter placement received acupuncture immediately prior to surgery. Eighteen semi-permanent intradermal needles were inserted on either side of the spine, and four were inserted in the legs and auricles. Needles were removed after four weeks. Using a numerical rating scale, pain was measured on the first five postoperative days. After discharge, pain was assessed using the Brief Pain Inventory at 7, 30, 60 and 90 days. RESULTS: Thirty-six patients were treated with acupuncture. Of these, 25, 23, and 22 patients provided data at 30, 60, and 90 days, respectively. The intervention was well tolerated by patients with only one minor and transient adverse event of skin ulceration. CONCLUSION: The rate of data completion met our predefined criterion for determining a randomized trial to be feasible (at least 75% of patients tolerated the intervention and provided evaluable data). This novel intervention is acceptable to patients undergoing thoracotomy and does not interfere with standard preoperative care. There was no evidence of important adverse events. We are now testing the hypothesis that acupuncture significantly adds to standard perioperative pain management in a randomized trial.

Journal Article↗
PubMed1993

En bloc resection for cancer of the gastric cardia without thoracotomy.

Thirty-five consecutive patients underwent en bloc resection of cardia cancer without thoracotomy. All tumors were adenocarcinoma. The operative procedure involved wide resection of the peri-hiatal diaphragm, dissection of the upper abdominal and lower mediastinal lymph nodes, and resection of the stomach including a portion of the lower thoracic esophagus without thoracotomy. The resection area of the diaphragm included not only the crural muscle as in other methods, but also the diaphragmatic tissue surrounding the esophageal hiatus. Through the enlarged hiatus, dissection of the mediastinum was possible up to the carina from the abdominal cavity. The mediastinal node stations were affected in 25% of patients whose tumor invaded to the serosa. Hypotension with or without atrial arrhythmias and pleural tears occurred during surgery in 20 patients (57%) and in 18 patients (51%), respectively. Postoperatively, hypoxia requiring reintubation developed in 7 patients (19%), pleural effusions needed tube drainage in 16 patients (46%), atelectasis in 5 patients (14%), and anastomotic leaks in 3 patients (9%). They were all successfully treated. The cumulative 5-year survival rate for 21 patients with stages I (2 patients), II (9), and III (10) diseases was 62%, whereas none of the patients with stage IV disease lived for more than 2 years after surgery. Because thoracotomy is avoided, the procedure is better tolerated by debilitated patients. We believe this technique is a reasonable and safe alternative to the left thoracotomy approach for resection of cancer of the gastric cardia.

Adenocarcinoma↗
PubMed1987

Anatomical basis of modern thoracotomies: the latissimus dorsi and the "serratus anterior-rhomboid" complex.

The latissimus dorsi and the "serrato-rhomboid" complex are the muscles most often involved in present-day thoracotomies for lung surgery. The present anatomic study emphasizes: the continuity between the serratus anterior and the rhomboid levator scapulae mass as a wide muscular sheet with a deep common fascia, extending the serrato-thoracic space (of Gillis) to the vertebral column as the rhomboserrato-thoracic space (the levator scapulae is situated higher up, above the ordinary thoracotomy); the presence of a "composite fascia" in the posterior angle between the seratus anterior and the rhomboid; the long costal attachment area and the presence of two differently oriented layers for the muscular digitations of the middle and inferior parts of the serratus anterior. With a rich vascular supply from multiple sources, the serratus anterior and latissimus dorsi are two large flat muscles with a single longitudinal nervous pedicle proceeding from the brachial plexus. To avoid esthetic (winged scapula) and functional sequelae, it is imperative to safeguard this single innervation as far as possible : by halting division of the serratus anterior before reaching its neurovascular pedicle in lateral or anterolateral thoracotomy, and by transecting the latissimus dorsi very low down in standard postero-lateral thoracotomy. The other muscles are simply freed and retracted.

Humans↗
PubMed1989

Intrapleural analgesia for post-thoracotomy pain and blood levels of bupivacaine following intrapleural injection.

An epidural type catheter was placed in the pleural space under direct vision before the closure of the chest in 24 patients who underwent thoracotomy for various types of lung or aortic surgery. All patients received intrapleural injections of 20 ml of 0.5 per cent bupivacaine with or without epinephrine as initial pain therapy. Patients also received subsequent doses of a similar volume of 0.375 per cent bupivacaine with epinephrine 1:200,000 up to four times a day for a maximum duration of seven days. Good pain relief was achieved in patients who underwent lateral and posterior thoracotomies. No pain relief was achieved in patients who underwent anterior thoracotomy or in patients in whom there was excessive bleeding in the pleural space. Bupivacaine blood concentrations were measured in 11 patients following the initial dose of 20 ml of 0.5 per cent bupivacaine (with epinephrine 1:200,000 in five of the 11 patients). The mean peak plasma concentration of bupivacaine when used with epinephrine was 0.32 +/- 0.02 microgram.ml-1. The mean peak plasma concentrations of bupivacaine when used without epinephrine was 1.28 +/- 0.48 microgram.ml-1. Our present data show that intrapleural analgesia is useful in the management of postoperative pain in patients who undergo thoracotomy. Our data also show that there is a significant decrease in peak plasma concentrations of bupivacaine when epinephrine is added to the solution (P less than 0.05).

Adult↗
PubMed1998

[Repair of intrathoracic visceral damage using video-assisted thoracoscopic surgery for blunt chest trauma and rib fixation at the site of mini-thoracotomy].

We treated three patients with intrathoracic visceral damage caused by severely dislocated fractured ribs resulting from blunt trauma by using video-assisted thoracoscopic surgery (VATS) and rib fixation through a mini-thoracotomy. Under general anesthesia and unilateral respiration, the thoracic cavity was inspected with a thoracic video scope through the port inserted through the thoracic drainage opening which was made upon arrival at hospital. As the visceral damage seemed restorable under VATS, a mini-thoracotomy was positioned just above the rib fracture. Two thoracic ports were inserted through the site of rib fracture or through the intercostal space and then VATS was performed using three ports. After the restoration of intrathoracic visceral damage, the fractured rib was fixated using a bioabsorbable poly-L-lactide rib fixation pin or a marlex mesh. Lung injuries were sutured and ligated under VATS in two of our cases and a spur of the fractured rib was shaved in one case. Only severely dislocated ribs were fixated through the mini-thoracotomy in all cases. Air leakage stopped just after this procedure and there were no complications. The rib fixation and bone regeneration were excellent after this procedure. The advantages of this method are the visceral restoration under VATS through a mini-thoracotomy and the ability to perform rib fixation without injuries to the intercostal muscle, artery, vein or nerve. This operative procedure is recommended for intrathoracic visceral damage caused by severely dislocated rib fracture.

Adult↗
PubMed1998

Lobectomy: video-assisted thoracic surgery versus posterolateral thoracotomy.

BACKGROUND: Video-assisted lobectomy has been adopted by many thoracic surgeons, because it is a less invasive approach to small peripheral lung cancers. However, some authors disagree that video-assisted lobectomy is less invasive than traditional thoracotomy and lobectomy. The purpose of this study was to evaluate the advantages of video-assisted lobectomy over posterolateral thoracotomy and lobectomy in terms of pain-related morbidity. METHODS: A total of 70 patients with clinical T1N0M0 non-small-cell lung carcinomas underwent lobectomy with complete mediastinal lymphadenectomy. Of these 35 underwent posterolateral thoracotomy (between April 1994 and December 1995; open group), and 35 underwent video-assisted thoracic surgery (VATS) (between January and December 1996; VATS group). RESULTS: Although the operative time was significantly longer in the VATS group (p = 0.04), the intraoperative blood loss was significantly less (p = 0.03). No significant differences were found for the two groups with respect to the total number of mediastinal lymph nodes dissected or duration of chest tube drainage. Postoperative pain was less severe as determined by the number of doses of analgesics required between postoperative days 0 and 7 (p < 0.0001), and the length of postoperative hospitalization was shorter in the VATS group (p < 0.0001). CONCLUSION: Video-assisted lobectomy is associated with decreased postoperative pain and shortened length of postoperative hospitalization, when compared with posterolateral thoracotomy and lobectomy.

Adult↗
PubMed2005

Comparison of thoracoscopic drainage with open thoracotomy for treatment of paediatric parapneumonic empyema.

The purpose of this study was to compare the efficacy of thoracoscopic drainage with open drainage of empyema in children. A retrospective case history audit was done of children presenting to a single major paediatric centre who underwent thoracoscopy drainage and decortication or open decortication and drainage (thoracotomy) between January 2000 and September 2002. Time to resolution of infection, duration of intercostal catheter (ICC) drainage, postoperative morphine requirements, and length of hospital admission were compared as primary measures of outcome. Thirty-three patients, 17 male and 16 female, aged between 1 month and 21 years were included in the study. Median age at surgery was 2.6 years. The location of the empyema was right-sided in 17 patients and left-sided in 16 patients. The empyema was drained by thoracoscopy in 11 patients, and 22 patients underwent thoracotomy. Two patients had thoracoscopy converted to thoracotomy for late-stage disease requiring greater surgical access. There were no differences between treatment groups with respect to duration of ICC drainage (p=0.6), duration of fever (p=0.6), length of stay (p=0.9), or postoperative morphine use (p=0.2). However, overall pain scores were lower in the thoracoscopy group, particularly on days 2 and 3; this approached statistical significance (p=0.07). This study has demonstrated that thoracoscopic drainage is an effective procedure for treating empyema in children. It is less invasive than open thoracotomy and is associated with less patient discomfort and less severe pain as measured by objective pain scores. We advocate thoracoscopic drainage for the majority of patients with empyema, except for those with advanced disease.

Adolescent↗
PubMed2003

Comparison of three-field esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy.

BACKGROUND: Thoracoscopic esophagectomy for esophageal cancer has been performed as an alternative to open surgery to reduce surgical trauma. However, its effect on pulmonary function, exercise tolerability, and quality of life is unknown. METHODS: Fifty-one patients with esophageal cancer underwent thoracic esophagectomy with radical lymphadenectomy by posterolateral thoracotomy (29 cases) or thoracoscopic surgery (22 cases). Patients performed spirometry and exercise tolerance testing and completed a quality-of-life questionnaire before and 3 months after surgery. RESULTS: Pre-to-postoperative change in vital capacity was 74.3 +/- 10.6% in the thoracotomy group and 84.9 +/- 10.4% in the thoracoscopy group (p = 0.021). Maximum oxygen uptake was similar, but dyspnea was the more common factor limiting exercise tolerance postoperatively in the thoracotomy group. Change in pre-to-postoperative performance status was 1.20 +/- 0.62 in the thoracotomy group and 0.55 +/- 0.51 in the thoracoscopy group (p = 0.0003). CONCLUSIONS: Thoracoscopic esophagectomy for esophageal cancer has better preservation of pulmonary function and quality-of-life.

Adult↗
PubMed2006

Extrapleural pneumonectomy via a lower door open thoracotomy with reconstruction of the diaphragm and pericardium using autologous materials for mesothelioma.

We performed extrapleural pneumonectomy (EPP) with combined resection of the diaphragm and pericardium via a lower door open (LDO) thoracotomy to treat right malignant pleural mesothelioma (MPM) in a 57-year-old man. Specifically, we extended the standard posterolateral thoracotomy skin incision along the anterior costal arch, and performed the thoracotomy by cutting into the 6th to 9th costal cartilage. The resulting defect of the diaphragm and pericardium were reconstructed with a reversed latissimus dorsi (LD) muscle flap and a fascia lata graft, respectively. The patient had an uneventful postoperative course without dyspnea or dysfunction of the extremities. The LDO thoracotomy provided a good operative field, especially for the costo- and cardiophrenic angles, allowing a complete resection of the diaphragm to be performed easily. Furthermore, the reversed LD muscle flap and fascia lata graft proved to be ideal autologous materials for reconstruction of both the diaphragm and the pericardium.

Diaphragm↗
PubMed2001

Intrathoracic transposition of a pectoralis major and pectoralis minor muscle flap for empyema in patients previously subjected to posterolateral thoracotomy.

The latissimus dorsi muscle flap cannot be used to eliminate an empyema cavity in patients who have previously undergone posterolateral thoracotomy, because of the division of this muscle. Moreover, thoracoplasty alone cannot sufficiently eliminate an empyema cavity that includes the thoracic apex, where space remains between the clavicle and the first rib. Therefore, we constructed a flap from the pectoralis major (P.Ma) and pectoralis minor (P.Mi) muscles to eliminate empyema cavities in five patients who had undergone lobectomy (n = 3) or pneumonectomy (n = 2) via posterolateral thoracotomy from 3 months to 40 years previously. All five patients had bronchopleural fistulae, and because of the previous upper lobectomy or pneumonectomy, they had large empyema cavities including the thoracic apex. Open-drainage thoracotomy was performed due to severe infection, and intrathoracic transposition of the P.Ma and P.Mi muscle flap with simultaneous thoracoplasty was carried out 7-124 weeks (mean 38 weeks) later. The P.Ma and P.Mi muscle flap easily reached the apex space with sufficient obliteration of the empyema cavity. All of the patients remained free of empyema 12-85 months after thoracic closure. The P.Ma and P.Mi muscle flap is useful for eliminating empyema cavities including the thoracic apex in patients who have previously undergone a posterolateral thoracotomy.

Aged↗
PubMed1993

Phrenic nerve damage via a right thoracotomy in older children with secundum ASD.

Phrenic nerve damage (PND) in children after cardiac operations is now recognized as being more frequent than previously thought. In a prospective study on 400 children, we previously demonstrated electrophysiologic evidence of postoperative PND in approximately 16% of patients, with one third of cases occurring in children under 18 months. In the past 18 months, 30 children have had atrial septal defect (ASD) repairs as their only operative procedure. Fourteen children had ASD repairs via a midline incision, and 16 ASD repairs were via a right thoracotomy. No PND (assessed by phrenic nerve latency) was found after a midline approach. In the right thoracotomy group, 5 children had evidence of PND (31%; p = 0.05). Four of these 5 patients were female and more than 14 years of age. The incidence of damage in this pubescent group was 80% (p < 0.05). In the older age group the duration of ventilation was not prolonged, but affected patients had symptoms of fatigue and breathlessness postoperatively. These data suggest a strong association between right thoracotomies for ASD repairs and PND, especially in the female pubescent group when a low submammary skin incision (seventh to eighth space) is used with a fifth to sixth space entry into the thoracic cavity. In conclusion, the right thoracotomy approach for ASD repair appears to be a significant risk factor for PND in older children.

Adolescent↗
PubMed1994

Video-assisted thoracoscopic surgery versus thoracotomy for spontaneous pneumothorax.

In a prospective comparison, 60 patients suffering from complicated spontaneous pneumothorax were randomly allocated to receive treatment by a video-assisted thoracoscopic surgery (VATS) technique or by thoracotomy. Thirty patients underwent bullectomy and apical pleurectomy by VATS performed through three 2-cm incisions (group V) and 30 patients underwent a similar surgical procedure through a posterolateral thoracotomy (group T). The median operating time was significantly longer in group V (45 versus 37.5 minutes; p < 0.05), but the postoperative analgesic requirement and hospital stay were less than those in group T. On the third postoperative day, the reductions in the forced expiratory volume in 1 second and forced vital capacity were significantly lower in group V than in group T (p < 0.05 and p < 0.01, respectively). Initial treatment of the spontaneous pneumothorax was effective in 27 patients (90%) in group V and in 29 patients (97%) in group T. There have been two late recurrences in group V and one in group T at a median follow-up of 15.1 months and 16.3 months, respectively. Within the study group, 30 consecutive patients presented with primary spontaneous pneumothorax. In this subgroup there was no significant difference in the operating time between VATS and thoracotomy, but postoperative pain, hospital stay, and pulmonary dysfunction were all less for those undergoing VATS. All treatment failures were in the subgroup of 30 consecutive patients who presented with secondary spontaneous pneumothorax, and the hospital stay in this group was prolonged by the use of VATS. We conclude from our findings that VATS is superior to thoracotomy in the treatment of primary spontaneous pneumothorax.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

Right anterolateral thoracotomy for repair of atrial septal defect.

BACKGROUND: To procure a cosmetic incision in female patients, we performed operation on atrial septal defects through a right anterolateral thoracotomy. METHODS: From 1984 to 1994, 80 female patients with a mean age of 24 +/- 13 years (ranging from 12 to 62 years) underwent right anterolateral thoracotomy for atrial septal defect repairs. Defects repaired included 62 ostium secundum, 12 sinus venosus, 2 low septal defect, and 4 ostium primum. The right iliac external artery was systematically used for arterial cannulation, through a cosmetic incision. Repairs were always performed under fibrillation, except in the 4 ostium primum defects, for which cardioplegia was used. RESULTS: There was no operative or late mortality, and no morbidity directly related to the thoracotomy approach. CONCLUSIONS: The right thoracotomy incision appears to be a safe and effective alternative to median sternotomy for repair of atrial septal defects.

Adult↗
PubMedDate not supplied

Emergency department thoracotomy for traumatic cardiac arrest.

There continues to be a debate on the indications for and value of emergency department thoracotomy, especially with regard to thoracotomies performed by emergency physicians. The current literature does not deal specifically with thoracotomies performed by an emergency physician on trauma patients in full cardiopulmonary arrest in a setting with no immediate surgical backup. This paper reports the results of 6 years of experience by one emergency physician in such a setting involving 80 patients, with a 6% overall survival rate, including two patients who survived blunt traumatic cardiac arrests. This lends support to emergency-physician-performed thoracotomies on trauma patients in "extremis," even in the setting of a hospital with no immediate surgical backup.

Adolescent↗
PubMed1993

Pain management and spirometry following thoracotomy: a prospective, randomized study of four techniques.

Forty-five patients who underwent anterolateral and posterolateral thoracotomy were studied to compare the relative efficacy of cryoanalgesia, epidural morphine, intrapleural analgesia, and intravenous morphine for relief of postoperative pain and prevention of deterioration in pulmonary function. Spirometry (FEV1, FVC) was performed preoperatively and postoperatively. Patients' pain was assessed using the 0 to 100 mm visual analog scale. Because intravenous morphine was used to supplement pain relief in the patients who received intrapleural analgesia and cryoanalgesia, total morphine use was compared to that administered to patients in the intravenous morphine group. Epidural morphine was found to offer better pain relief than the other treatment modalities. There were no differences in spirometric testing between the groups at any time during the study. Although the number of evaluable patients was insufficient to draw definitive conclusions, 12-week follow-up suggested a difference in the incidence of post-thoracotomy pain syndrome in patients who received cryoanalgesia. It is concluded that post-thoracotomy pain is best relieved with epidural morphine, compared to intrapleural analgesia, cryoanalgesia, and parenteral morphine. There was no change in the deterioration in spirometric tests after thoracotomy, nor was there any advantage offered by cryoanalgesia or intrapleural analgesia over intravenous morphine, with respect to pain relief.

Aged↗
PubMed2005

Minimally invasive midaxillary muscle sparing thoracotomy for atrial septal defect closure in prepubescent patients.

BACKGROUND: Partial sternotomy, as well as posterolateral or anterolateral right-sided thoracotomy, are used for correction of selected cardiac lesions in children. However, in female patients impaired breast development after an anterolateral thoracotomy is reported, and for both the posterolateral and the anterolateral approach, partial transection of large muscle groups is required. The midaxillary approach may help to avoid these side effects and improve the cosmetic result. METHODS: Beginning in April 2003, our institutional policy changed toward a midaxillary approach in prepubescent patients with an atrial septal defect, in whom criteria for catheter closure were not fulfilled. Thoracotomy was performed after a horizontal midaxillary incision and mobilization of the latissimus dorsi and splitting of the serratus anterior. Aorta and caval veins were cannulated directly. The atrial septal defect was closed during electrically induced fibrillation of the heart. RESULTS: Until August 2004, this technique was applied in 36 patients (30 girls, 6 boys), with no need for conversions to another approach. Mean patient age was 6.9 +/- 2.6 years (range, 4 to 14 years), with a mean weight of 23.8 +/- 11.2 kg (range, 15 to 69 kg). Skin incision ranged from 4.5 to 6.0 cm. Mean cardiopulmonary bypass time was 31 +/- 13 minutes (range, 13 to 73 minutes), with a mean ventricular fibrillation time of 21.2 +/- 7.4 minutes (range, 10 to 42 minutes). In 28 of 36 patients a patch was used. No phrenic nerve damage occurred. CONCLUSIONS: The midaxillary approach is a safe alternative to lateral thoracotomies frequently used in cardiac surgery for atrial septal defect closure. It helps to improve the cosmetic result in the prepubescent patient group. We believe that its application should not be expanded to include repair of more complex lesions or to patients below the age of 3 to 4 years. For these, variations of cosmetically favorable partial sternotomy techniques should be applied.

Adolescent↗