Diverse clinical presentation of primary spontaneous pneumothorax in patients with pectus excavatum.

Objective: Patients with primary spontaneous pneumothorax (PSP) tend to be young, tall, and thin, as do those with pectus excavatum (PE). Notably, the Haller index, which measures the severity of PE, tends also to be higher in patients with PSP, further suggesting a potential predisposing factor for the development of PSP in individuals with PE. This study aimed to share clinical experiences with case series of concomitant PSP and PE and to emphasize the importance of evaluating these two conditions together. Methods: In this single-center study, we conducted a retrospective records review to identify patients who were diagnosed and treated (including surgical or conservative treatment and follow-up observation) for the diagnosis of PE between July 2011 and February 2023. From these, we selected patients who were diagnosed with both PE and PSP and analyzed their clinical presentations. Results: Among a total of 139 patients with PE, there were 8 (5.76%) who had concurrent diagnoses of PE and PSP and who underwent surgery for PSP, PE, or both. The average age of these 8 patients (male:female = 7:1) was 19.38 years. The 8 patients were grouped into four categories based on their clinical scenarios. Group A had 1 patient with PE diagnosed first, followed by the discovery of PSP during evaluation; Group B included 2 patients initially presenting with PSP and subsequently diagnosed with PE during evaluation; Group C consisted of 1 patient who had PSP before undergoing surgical PE correction; and Group D comprised 4 patients who developed PSP after PE correction. Conclusions: The incidence of PSP in patients with PE was 5.76% (8 out of 139 patients), indicating the importance of vigilant monitoring for PSP prior to PE surgery, and vice versa. Furthermore, the authors recommend close observation for PSP independent of PE surgery, even in the absence of postoperative complications.

Use of thoracoscopy for thoracic sympathetic nerve block in primary hyperhidrosis.

Thoracic sympathetic nerve block (TSNB) has been widely used in the treatment of neuropathic pain. To reduce block failure rates, TSNB is assisted with several modalities including fluoroscopy, computed tomography, and ultrasonography. The present study describes our experience assessing the usefulness of thoracoscopy in TSNB for predicting compensatory hyperhidrosis before sympathectomy in primary hyperhidrosis. From September 2013 to October 2021, TSNB was performed under local anesthesia using a 2-mm thoracoscope in 302 patients with severe primary hyperhidrosis. Among the 302 patients, 294 were included for analysis. The target level of TSNB was T3 in almost all patients. The mean procedure time was 21 min. Following TSNB, the mean temperature of the left and right palms significantly changed from 31.5 to 35.3 °C and from 31.5 to 34.8 °C, respectively. With TSNB, primary hyperhidrosis was relieved in all patients. Pneumothorax occurred in six patients, in which no chest tube insertion was required. One patient developed hemothorax and was discharged the next day after small-bore catheter drainage. Transient ptosis developed in 10 patients and improved within a day in all patients. Our experiences showed that thoracoscopic TSNB is accurate, safe, and feasible to block the thoracic sympathetic nerve in patients with severe primary hyperhidrosis.

Thoracoscopic sympathetic block to predict compensatory hyperhidrosis in primary hyperhidrosis.

BACKGROUND: Compensatory hyperhidrosis is the main cause of patients' dissatisfaction following sympathectomy for primary hyperhidrosis. Therefore, thoracoscopic sympathetic nerve block before sympathectomy can be used to predict compensatory hyperhidrosis after sympathectomy. The objective of this study is to review our recent experience with the nerve block procedure, describing efficacy, safety and validity. METHODS: We retrospectively reviewed the medical records of 107 patients who underwent thoracoscopic sympathetic nerve block with a local anesthetic for primary palmar and craniofacial hyperhidrosis using a 2-mm needlescope from March 2017 to November 2019. A week later, the patients were interviewed, and a decision made as to whether to proceed with sympathectomy. We analyzed the perioperative data of patients who underwent the predictive procedure either followed, or not followed, by sympathectomy. RESULTS: Primary hyperhidrosis was relieved in all patients by the predictive procedure without severe complications. Compensatory hyperhidrosis happened to 32 patients (29.9%). Seventy-eight patients (72.9%) decided to undergo sympathectomy (group A) and 29 patients (27.1%) refused the sympathectomy (group B). Group B tended to have higher average body mass index (24.5 versus 23.2 kg/m2, P=0.082) and compensatory hyperhidrosis rate after predictive procedure (37.9% versus 26.9%, P=0.269) compared to group A. The compensatory hyperhidrosis rate after sympathectomy in group A was 76.9%. The effective duration of sympathetic block was significantly longer in group A than in group B (33.5 versus 13.9 hours, P=0.001). The predictive procedure had 94.4% specificity and 33.3% sensitivity for prediction of compensatory hyperhidrosis. CONCLUSIONS: Thoracoscopic sympathetic block may be safe and feasible as a procedure for predicting compensatory hyperhidrosis after sympathectomy, and beneficially, it allows the patients to experience the effect of sympathectomy on primary hyperhidrosis and occurrence of compensatory hyperhidrosis. However, a longer effective duration of sympathetic block is needed to help patients to decide whether to proceed with the surgery.

Quadrangular Fixation of Pectus Bars to Prevent Displacement in Nuss Procedure.

BACKGROUND: Double pectus bars are sometimes inserted to correct pectus excavatum. Method of double-bar fixation to prevent bar displacement has been rarely reported. We have used quadrangular fixation of the double pectus bars. The objective of this study was to compare results of the quadrangular fixation procedure with those of the classic separate fixation procedure. METHODS: From September 2011 to January 2016, 86 patients underwent Nuss procedure with double-bar insertion. In 44 patients, each bar was fixed separately (group A). In 42 patients, quadrangular fixation of the bars was performed with metal plates (group B). Patient demographics, Haller index (HI), bar displacement index (BDI), and reoperation rate were compared between the two groups. RESULTS: The mean patient age was 17.2 years (range: 3-40 years) in group A and 17.8 years (range: 4-30 years) in group B. There was no significant difference in preoperative or postoperative HIs between the two groups (all p >0.05). Early complication rates were 15.9% in group A and 9.5% in group B (p > 0.05). In group A, three patients underwent surgery to correct bar displacement (6.8% of reoperation rate), whereas there was no corrective surgery in group B. BDIs of the two groups were significantly different (p < 0.01). CONCLUSIONS: When quadrangular fixation was performed with upper and lower pectus bars bilaterally fixed by connecting each bar with plates, bar displacement was prevented more effectively than separate fixation, thus minimizing reoperation.

Robotic lobectomy for lung cancer: initial experience of a single institution in Korea.

BACKGROUND: Robotic surgery is known to have several advantages including magnified three-dimensional vision and angulation of the surgical instruments. To evaluate the feasibility and efficiency of robotic lobectomy in the treatment of lung cancer, we analyzed the outcomes of our initial experiences with robotic lobectomy at a single institution in Korea. METHODS: Eighty-seven patients with lung cancer underwent robotic lobectomy (robotic group: 34 patients) and video-assisted thoracic surgery (VATS) lobectomy (VATS group: 53 patients) between 2011 and 2016 at our hospital. The medical records of these patients were retrospectively analyzed. RESULTS: The operation times of the two groups were significantly different (robotic group, 293±74 min; VATS group, 201±62 min; P<0.01). Intraoperative blood loss occurred more in the robotic group than in the VATS group (robotic group, 403±197 mL; VATS group, 298±188 mL; P=0.018). The numbers of lymph nodes dissected in the two groups were significantly different (robotic group, 22±12; VATS group, 14±7; P<0.01). There was no intraoperative mortality in both groups. CONCLUSIONS: Despite the initial difficulties, robotic lobectomy for lung cancer was a safe and feasible procedure with no operative mortality. If operation time and intraoperative blood loss improve as the learning curve progresses, robotic surgery may overcome the limitations of VATS in lung cancer surgery.

Brachial plexus palsy after Nuss procedure for pectus excavatum.

Brachial plexus palsy rarely occurs after Nuss procedure for pectus excavatum. Brachial plexus palsy after surgery may be caused by nerve tension and compression related to surgical positioning. In this article, we report a 21-year-old male patient of brachial plexus palsy after Nuss procedure revealing a narrowing of the costoclavicular space from 7.60 mm to 2.83 mm and an increase to 4.51 mm after upper bar removal. Patient"s symptoms were fully recovered. Our results showed that narrowing of the costoclavicular space after Nuss procedure might trigger brachial plexus palsy and that brachial plexus palsy may not be related to surgical positioning.

A clinical decision-making model for repeat surgical treatment of pectus Bar displacement: distance measurement after nuss procedure.

BACKGROUND: Bar displacement is one of the most common and serious complications after the Nuss procedure. However, measurements of and factors affecting bar displacement have not been reported. The objectives of this study were to develop a decision model to guide surgeons considering repeat treatment and to estimate optimal cut-off values to determine whether reoperation to correct bar displacement is warranted. METHODS: From July 2011 to August 2013, ninety bars were inserted in 61 patients who underwent Nuss procedures for pectus excavatum. Group A did not need surgical intervention and Group B required reoperation for bar displacement. Bar position was measured as the distance from the posterior superior end of the sternal body to the upper border of the metal bar on lateral chest radiographs. The bar displacement index (BDI) was calculated using D0 - Dx / D0 x 100 (D0: bar position the day after surgery; Dx: minimal or maximal distance of bar position on the following postoperative days). The optimal cut-off values of BDI warranting reoperation were assessed on the basis of ROC curve analysis. RESULTS: Of the 61 patients, 32 had single bars inserted whereas 29 had parallel bars inserted. There was a significant difference in age (14.0 ± 7.5 vs. 23.3 ± 12.0, p = 0.0062), preoperative Haller index (HI) (4.0 ± 1.1 vs. 5.0 ± 1.0, p = 0.033), and postoperative HI (2.7 ± 0.4 vs. 3.2 ± 0.5 p = 0.006) between the two groups. The optimal cut-off value of BDI was 8.7. CONCLUSIONS: We developed a BDI model for surgeons considering performing reoperation after Nuss procedure. The optimal cut-off value of BDI was 8.7. This model may help surgeons to decide objectively whether corrective surgery should be performed. The main factors affecting the relationship between bar displacement and reoperation were age and preoperative HI.

Prediction of compensatory hyperhidrosis with botulinum toxin A and local anesthetic.

OBJECTIVE: Compensatory hyperhidrosis (CH) is one of the most problematic complications of sympathectomy, which occurs often and is hard to treat. A predictive procedure (PP) for CH can help patients experience compensatory sweating before sympathectomy to determine whether or not to perform sympathectomy. Our study aimed to evaluate the CH after the PP and sympathectomy in patients with primary palmar hyperhidrosis using multiple drugs. METHODS: We reviewed 83 patients who underwent a PP between July 2009 and August 2013 with primary palmar hyperhidrosis. In group A, we used levobupivacaine (n = 39). In group B, we used botulinum toxin A plus ropivacaine for the PP in group B (n = 44). RESULTS: The CH rate after the PP was 44 % (group A) and 25 % (group B), and after sympathectomy 80 % (group A) and 75 % (group B). The prediction value between the PP and the sympathectomy was statistically significant in group A (p < 0.05). The positive prediction rate was 73 % and the negative prediction rate was 27 % in group A. CONCLUSIONS: Local anesthetic alone has a better predictive value. From our finding, patients should be made aware that CH after sympathectomy is less severe in 73 % of cases than that experienced in the PP.

The effectiveness of pregabalin for post-tonsillectomy pain control: a randomized controlled trial.

BACKGROUND: Although various analgesics have been used, postoperative pain remains one of the most troublesome aspects of tonsillectomy for patients. OBJECTIVE: The aim of the present study was to evaluate the effectiveness of premedication using pregabalin compared with placebo (diazepam) on postoperative pain control in patients undergoing tonsillectomy. METHODS: Forty-eight adult patients were randomly divided into a control group and a pregabalin group. Preoperatively, patients in the control group received 4 mg diazepam orally as placebo, whereas those in the pregabalin group received 300 mg pregabalin orally. All participants were provided with patient-controlled analgesia using fentanyl for 24 hours after surgery. Postoperative pain treatment included acetaminophen 650 mg three times daily for 8 postoperative days. The primary outcome measure was the total amount of patient-controlled fentanyl consumption after tonsillectomy. Secondary outcome measures were the number of injections of ketorolac tromethamine (each 30 mg) requested by patients, pain scores, overall satisfaction scores, drowsiness, nausea, dizziness, headache, and vomiting after the surgery. P < 0.05 was considered statistically significant. RESULTS: The total amount of fentanyl demanded decreased significantly in the pregabalin group (P < 0.001). There were no significant differences in the number of ketorolac tromethamine injections, pain scores, overall satisfaction scores, drowsiness, nausea, dizziness, headache, and vomiting between the two groups. CONCLUSION: Administration of 300 mg pregabalin prior to tonsillectomy decreases fentanyl consumption compared with that after 4 mg diazepam, without an increased incidence of adverse effects. TRIAL REGISTRATION: KCT0001215.

The effectiveness of gabapentin on post-tonsillectomy pain control.

Postoperative pain is one of the most troublesome aspects of tonsillectomy for patients. Although various analgesics have been administered for pain control following tonsillectomy, it has still not been effectively controlled. Therefore, this study was conducted to evaluate the effectiveness of premedication using gabapentin on postoperative pain control in patients undergoing tonsillectomy. A total of 58 adult patients were randomly divided into a control group and a gabapentin group. Patients in the control group received an oral placebo preoperatively, whereas those in the gabapentin group received an oral dose of gabapentin preoperatively. All participants were provided with patient-controlled analgesia using fentanyl for 48 h after surgery. The total amount of fentanyl injected and the number of injections of dicolfenac sodium (75 mg each) requested by each of the group was then compared. Pain assessment was performed using a visual analog scale during resting periods (rVAS) and during swallowing (sVAS) for 9 days after the operation. The number of dicolfenac sodium injections and the total amount of fentanyl injected decreased significantly in the gabapentin group (P < 0.01). The sVAS of the gabapentin group was also significantly lower than that of the control group at 2 and 4 h after surgery, but there were no significant differences in the sVAS observed between the two groups for the remainder of the postoperative period. There were no significant differences in the rVAS observed between the two groups throughout the postoperative period. Thus, premedication with gabapentin decreased post-tonsillectomy pain. So the addition of gabapentin prior to tonsillectomy may have an adjunctive role in pain control.

Lactate concentrations in incisions indicate ischemic-like conditions may contribute to postoperative pain.

UNLABELLED: The substances in wounds that cause incisional pain and hyperalgesia after surgery are poorly understood. We have developed and characterized rat models for incision-induced pain behaviors and measured increased tissue hydrogen ion concentration. Because lactate may facilitate nociceptor responses to low pH and contribute to ischemic pain mechanisms, we measured tissue lactate after incision of the plantar region of the hindpaw, gastrocnemius muscle, and paraspinal region in halothane anesthetized rats using in vivo microdialysis. Incisions were performed at 1 site (plantar, gastrocnemius, or paraspinal incision) in each rat. The corresponding contralateral side was used as the control. In anesthetized rats, a microdialysis fiber was passed into the incision and the control side. L-Lactate was measured using the lactate oxidase method. Tissue concentration was determined from postoperative day 0 to postoperative day 14 using the no net flux method. Lactate was increased on the day of hindpaw incision to 3.6 +/- 1.6 mmol/L compared with control (2.1 +/- .6 mmol/L) and remained increased through 7 days. In the gastrocnemius muscle, lactate was increased the day after incision (4.2 +/- 1.2 mmol/L vs 1.7 +/- .5 mmol/L) until postoperative day 7. On the day of the paraspinal incision, lactate was 3.4 +/- 1.1 mmol/L on the operated side and 2.2 +/- .6 mmol/L in the control side. Lactate remained increased through postoperative day 8 at the paraspinal incision. These experiments demonstrate that incision of the plantar hindpaw, the gastrocnemius muscle, and the paraspinal region increased tissue lactate concentration. The wound environment contains increased lactate at the same time that pH is decreased; lactate could potentially facilitate nociceptor activation by low pH and contribute to pain after surgery. PERSPECTIVE: This study demonstrates that lactate is increased in wounds when pain behaviors and acid are increased. Lactate and low pH are present in incisions and indicate an ischemic pain mechanism that may contribute to postsurgical pain.

Strain and sex influence on pain sensitivity after plantar incision in the mouse.

BACKGROUND: A small surgical incision in mouse glabrous hind-paw skin induces short-lasting guarding behavior and mechanical and heat hyperalgesia-like behaviors, which imitate human postoperative pain. The increasing popularity of this animal model in drug discovery necessitates the understanding of genetic and sex influence on this animal model. METHODS: The authors examined pain behaviors on DBA2, C57Bl/6, and 129X1/SvJ mice and male and female DBA2 mice before and after plantar incision. RESULTS: The baseline nociceptive responses of these strains were similar, with a few exceptions. Heat responses were different between DBA2 and C57Bl/6 mice, and responses to one filament, 14.0 mN, were intermittently different. Sex did not greatly influence baseline responses. After plantar incision, these three strains of mice were not different in the development of guarding behaviors. Heat responses were only different on postincision day 3 (129X1/SvJ vs. C57Bl/6 mice); otherwise, they were the same. The responses to the series of von Frey filaments were the same after incision in the three strains. Sex did not influence incision-induced pain behaviors in DBA2 mice. CONCLUSION: Although several studies postulated that mouse strain influences pain models, the authors' data indicate that such influence on incisional pain is negligible. This suggests that studies using an incision and knockout mice resulting from 129 strain mutation in a C57BL/6 strain background should have modest influence. The lack of sex differences in incisional pain may encourage researchers to use both male and female subjects in their studies.

Changes in tissue pH and temperature after incision indicate acidosis may contribute to postoperative pain.

BACKGROUND: Incisional pain is a common form of acute pain. Previously, the authors studied persistent pain behaviors caused by incisions, using animal models for postoperative pain. In this study, the authors measured tissue pH and hind paw temperature before and after incision to understand factors that may activate and sensitize nociceptors in the incision. METHODS: Rats underwent a plantar incision, a gastrocnemius muscle incision, or a cutaneous paraspinal incision. For the hind paw incision, pain behaviors were measured. Tissue pH was measured using a pH-sensitive needle electrode in halothane-anesthetized rats. The pH in the incision was compared to a corresponding control site on the contralateral side of the rat or to the sham-operated group. RESULTS: Plantar tissue pH was 7.16 +/- 0.04 in sham-operated rats. Ten minutes after plantar incision, tissue pH was decreased to 6.91 +/- 0.20 (P < 0.05), and this decrease was sustained through 60 min after incision, when pH was 6.99 +/- 0.06 (P < 0.05). Tissue pH values were 6.95, 6.90, 6.89, and 6.95 (P < 0.05 vs. sham) 4 h and 1, 2, and 4 days after incision, respectively. On postoperative day 7, when plantar pH was same as for the control side (7.13 +/- 0.05), guarding behavior, heat responses, and responses to mechanical stimuli recovered. Outside the incised area in the hind paw, tissue pH was normal. Tissue pH was significantly correlated with all pain behaviors. In the gastrocnemius muscle, tissue pH was 7.14 +/- 0.7 in the sham-operated side. Ten minutes after incision, tissue pH was 6.54 +/- 0.12 (P < 0.05), and muscle pH remained decreased through 60 min after gastrocnemius incision when pH was 6.76 +/- 0.17 (P < 0.05). Tissue pH was also significantly decreased (P < 0.05) on day 1 (6.96 vs. 7.20) and day 4 (7.06 vs. 7.18) after gastrocnemius incision but was not reduced on postoperative day 8 (7.11 vs. 7.15). A paraspinal incision also decreased tissue pH in the hairy skin of the rat compared with the preincision value. Hind paw skin temperature did not change after incision. CONCLUSION: A decrease in pH occurs immediately after incision and is sustained for at least 4 days. During the period of decreased tissue pH, pain behaviors are evident. When the tissue pH returns to normal, pain behaviors are diminished. The decreased pH is localized at the incision site and not to areas surrounding the incision. Decreased pH likely contributes to nociceptor sensitization and pain related behaviors after incision. The magnitude of the pH change varies among tissues. An increase in hind paw skin temperature does not play a role in these pain-related behaviors.

Effect of blockade of nerve growth factor and tumor necrosis factor on pain behaviors after plantar incision.

UNLABELLED: To examine the role of nerve growth factor (NGF) in postoperative pain, we administered the tyrosine kinase A (Trk A) immunoglobulin G (IgG) fusion (1 to 10 mg/kg) molecule before and after plantar incision. We also pretreated rats with a tumor necrosis factor receptor (TNFr) protein, p75 IgG fusion protein (5 to 10 mg/kg), to study the role of endogenous TNF in the development of pain behaviors after incision. Rats underwent a plantar incision, and responses to punctate and nonpunctate mechanical stimuli and withdrawal latency to radiant heat were measured. Rats were tested on the day of incision and daily for 4 days. Reduced withdrawal latency to radiant heat occurred after incision in the control group treated with IgG. Both pretreatment and treatment after incision with 5 mg/kg dose of Trk A IgG fusion protein increased the withdrawal latency to heat in incised rats (P <.05) through 4 days. A similar effect was observed after 10 mg/kg was administered after incision. Neither dose influenced the reduced withdrawal threshold and increased response to blunt mechanical stimulation caused by the incision. Pretreatment with 5 or 10 mg/kg of TNFr IgG fusion protein had no effect on any of the incision-induced pain-related behaviors. We conclude that sequestration of NGF affected responses to heat after incision but did not influence responses to mechanical stimuli. Thus, fibers sensitive to heat are influenced by NGF and probably do not contribute to exaggerated responses to mechanical stimuli. TNF does not appear to have a role in the pain behaviors. PERSPECTIVE: To treat postoperative pain better, we should discover the factors that are causing incisional pain. One endogenous factor that contributes to pain after incision is NGF. Inhibition of NGF may provide a new way to treat pain after surgery with minimal side effects. This could improve outcome after surgery.