Analysis of Pain Management after Anatomic VATS Resection in Austrian Thoracic Surgery Units.

BACKGROUND: Postoperative pain influences rehabilitation, postoperative complications and quality of life. Despite its impact, there are no uniform treatment guidelines. Different centers seem to use various strategies. This study aims to analyze pain management regimens used after anatomic VATS resections in Austrian thoracic surgery units, with a special interest in opioid usage and strategies to avoid opioids. METHODS: A questionnaire was designed to assess the use of regional anesthesia, postoperative pain medication and characteristics of individual pain management regimens. The questionnaire was sent to all thoracic surgery units in Austria, with nine out of twelve departments returning them. RESULTS: All departments use regional anesthesia during the procedure. Four out of nine centers use epidural analgesia or an intercostal catheter for postoperative regional anesthesia in at least 50% of patients. Two departments follow an opioid restrictive regimen, five depend on the visual analogue scale (VAS) and two administer opioids on a fixed schedule. Three out of nine departments use NSAIDs on a fixed schedule. The most used medication is metamizole (eight out of nine centers; six on a fixed schedule, two depending on VAS) followed by piritramide (six out of nine centers; none as a fixed prescription). CONCLUSIONS: This study reflects the heterogeneity in postoperative pain treatment after VATS anatomic lung resections. All departments use some form of regional anesthesia in the perioperative period; prolonged regional anesthesia is not utilized uniformly to reduce opioid consumption, as suggested in enhanced recovery after surgery programs. More evidence is needed to optimize and standardize postoperative pain treatment.

Single incision laparoscopic cholecystectomy (SILC) versus laparoscopic cholecystectomy (LC)-a matched pair analysis.

INTRODUCTION: The aim of our study was to compare single incision laparoscopic cholecystectomy (SILC) and laparoscopic cholecystectomy (LC) with respect to complications, operating time, postoperative pain, use of analgesics, length of stay, return to work, rate of incisional hernia, and cosmetic outcome. METHODS: Sixty-seven patients underwent SILC. Of a cohort of 163 LC operated in the same time period, 67 patients were chosen for a matched pair analysis. Pairs were matched for age, gender, ASA, BMI, acuity, and previous abdominal surgery. In the SILC group, patient characteristics (gender, age, BMI, comorbidities, ASA, previous abdominal surgery, symptomatic cholecystolithiasis, cholecystitis) and perioperative data (surgeon, operation time, conversion rate and cause, intraoperative complications, postoperative complications, reoperation rate, VAS at 24 h, VAS at 48 h, use of analgesics according to WHO class, and length of stay) were collected prospectively. RESULTS: Follow-up in the SILC and LC group was completed with a minimum of 17 and a maximum of 26 months; data acquired were recovery time the patients needed until they were able to get back into the working process, long-term incidence of postoperative hernias, and satisfaction with cosmetic outcome. Operating time was longer for SILC (median 75 min, range 39-168 vs. 63, range 23-164, p = 0.039). There were no significant differences for SILC and LC with regard to postoperative pain measured by VAS at 24 h (median 3, range 0-8 vs. 2, range 0-8, p = 0.224), at 48 h (median 2, range 0-6 vs. 2, range 0-8, p = 0.571), use of analgesics, and length of stay (median 2 days, range 1-9 vs. 2, range 1-11, p = 0.098). There was no major complication in either group. The completion rate of SILC was 85.1% (57 of 67). Although there was a trend towards an earlier return to the working process in patients of the SILC group, this was not significant. The rate of incisional hernias was 1.9% (1/53) in the SILC and 2.1% (1/48) in the LC group indicating no significant difference. Self-assessment of satisfaction with the cosmetic outcome was not judged different by patients in both groups. CONCLUSION: SILC is associated with longer operating time, but equals LC with respect to safety, postoperative pain, use of analgesics, length of stay, return to work, rate of incisional hernia, and cosmetic outcome.

Temporary placement of self-expanding oesophageal stents as bridging for neo-adjuvant therapy.

BACKGROUND: Placement of self-expanding stents is an effective palliation for dysphagia in non-resectable oesophageal or proximal gastric cancer. The aim of this analysis was to assess the efficacy of temporary stent placement for dysphagia relief during neo-adjuvant treatment for locally advanced disease. METHODS: A total of 38 patients scheduled for neo-adjuvant chemo(radio)therapy for locally advanced oesophageal cancer (n = 29), cardia cancer (n = 8) or subcardial gastric cancer (n = 1) underwent placement of self-expanding plastic stents (n = 13) or covered metal stents (n = 25) due to severe dysphagia and weight loss. RESULTS: Instant dysphagia relief was achieved in 37 (97.4%) of 38 patients. Dysphagia scores declined from mean 3.0 +/- 0.7 before stent placement to 0.6 +/- 0.9 at restaging. After completion of the neo-adjuvant therapy 20 (52.6%) of the 38 patients underwent resection of the tumour, 5 patients (13.2%) underwent primary resection without receiving chemotherapy while 12 patients (31.6%) did not undergo surgery. Stent-related complications were observed as perforation (n = 1), mediastinitis (n = 1), tracheo-oesophageal fistula (n = 2), bleeding (n = 1) and jejunal perforation caused by a migrated stent (n = 1). Serum albumin significantly decreased in patients with progressive disease despite successful stenting (40.0 +/- 4.9 mg/dl versus 29.7 +/- 6.4 mg/dl, p < 0.05) while stable albumin levels were found in patients who underwent surgery (39.9 +/- 4.3 mg/dl versus 39.1 +/- 3.8 mg/dl, p = 0.484). CONCLUSION: Placement of self-expanding stents is highly effective for instant dysphagia relief, enabling adequate oral nutrition during neo-adjuvant therapy, but is limited by a high re-intervention rate.

The incidence of gastroesophageal reflux after transthoracic esophagocardio-myotomy without fundoplication: a long term follow-up.

OBJECTIVE: Evaluation of the long term results of Heller's myotomy performed over a lateral thoracotomy without additional fundoplication. METHODS: Forty patients (17 males, 23 females; mean age 43.2 years; range: 14-63 years) were operated between 1985 and 2000. Preoperative evaluation included clinical scoring of symptoms, esophagogram, endoscopy, manometry and 24-h ph-metry. At the follow-up investigation, the preoperative evaluation was repeated in all patients, adding a histological workup of the distal esophageal mucosa. The mean duration of follow-up after surgery was 10.3 years, ranging from 3-16 years. RESULTS: The clinical scores improved significantly: Excellent relief from dysphagia was present in 86%, little or no regurgitation was found in 79%, little or no retrosternal spasms were reported by 72% of the patients. Esophagogram showed an overall esophageal dilatation in all patients but no significant obstruction at the esophagogastric junction. Endoscopically, 2.5% had candida-esophagitis, 5% showed signs of a GERD I, 92.5% had a macroscopically insuspect esophageal mucosa. Histologically, 53% showed a mild chronic inflammation. Manometry demonstrated distinct hypomotility of the esophagus in all cases, yet no elevated pressure of the lower sphincter; pH-metry showed moderate reflux in 46%. CONCLUSIONS: Transthoracic cardiomyotomy is a valid method for the treatment of achalasia, but it will not improve the esophageal motility, which slowly deterioriates in these cases. The patient's subjective assessment of the postoperative result was positive in the majority of cases. Although fundoplication was not done in any of these patients, none of them showed signs of clinically relevant reflux.

Ultraflex stent--benefits and risks in ultimate palliation of advanced, malignant stenosis in the esophagus.

BACKGROUND/AIMS: Sophisticated endoscopical palliation in end-stage malignant stenosis of the esophagus and gastroesophageal-junction must be weighed against associated morbidity and mortality. In a prospective study we investigated benefits and risks of one type of coated, self-expandable stent in ultimate palliation of esophageal neoplasms focusing on factors that might predispose patients to develop complications. METHODOLOGY: 33 men (70.2%) and 14 women (29.8%), (mean age 68.3 years, range from 38 to 90 years), suffering from nonresectable malignant stenosis of the esophagus due to advanced tumor stage and/or functional inoperability were treated by using a covered, self-expandable stent (covered ULTRAFLEX esophageal stent system, Microinvasive, Boston Scientific Corporation, Boston, MA). Stenting was indicated because of severe dysphagia for liquids and saliva in 41 (87.2%) patients, tracheoesophageal fistula in 5 (10.6%) patients and in one case of tumor bleeding (2.1%). 32 out of 47 patients had had one or other multiple treatment modalities before stenting. In 15 patients stenting was the first and only therapeutic option. RESULTS: All patients experienced an improvement of dysphagia immediately after stenting. Eight out of 47 patients (17.1%) developed major stent-associated complications: Early complications within 4 days after implantation evolved in two cases, with one patient dying from stent-induced perforation with consecutive mediastinitis and multi-organ failure. Late complications (20 to 180 days after stent implantation) occurred in 6 cases: Three esophagotracheal fistulae (two with tracheal compression) induced by stent expansion, one stent-induced bleeding and two stent dislocations. After appropriate complication management all but two patients were able to be discharged after a mean of 2.6 days. Multivariate analysis did not show any factors that might have predicted the development of major stent-associated complications. CONCLUSIONS: Implantation of the self-expandable Ultraflex-stent will efficiently palliate dysphagia, bleeding and fistulae. The 17% risk of major complications seems acceptable regarding the inherent problems of alternative treatment options, like gastrostomy, PEG, nasogastric tube or long-term parenteral feeding.

Penetration of meropenem into pneumonic human lung tissue as measured by in vivo microdialysis.

Until recently, information on antibiotic pharmacokinetic properties in infected human lung tissue was limited. We therefore studied a microdialysis-based approach for measurement of the penetration of meropenem into the extracellular space fluid of human pneumonic lung parenchyma. The lung penetration of meropenem was determined for seven patients with pneumonia and metapneumonic pleural empyema treated by decortication. Intraoperatively, two microdialysis probes were inserted into pneumonic lung tissue and one was inserted into healthy skeletal muscle for reference values. Serum and microdialysis samples were collected at 20-min intervals for at least 8 h following a single intravenous dose of 1 g of meropenem. The maximum free interstitial concentration (mean and standard deviation) of meropenem in infected lung tissue was 11.4 +/- 10.9 mg/liter, and that in serum was 47.3 +/- 21.0 mg/liter. The areas under the curve for infected lung tissue (36.2 +/- 17.9 mg. h/liter) and serum (95.4 +/- 46.6 mg. h/liter) revealed a significant difference. This technique enabled quasi-continuous tissue pharmacokinetic measurements of free, unbound antibiotic in pneumonic lung tissue of patients with pneumonia. The present data corroborate the use of meropenem in the treatment of lung infections caused by extracellular bacteria, demonstrating the excellent distribution profile for meropenem in the interstitial space of human pneumonic lung tissue.

Emphysema of the abdominal wall obscuring postcesarean volvulus. A case report.

BACKGROUND: Emphysema of the abdominal wall occurs after infection with gas-forming organisms or when intraabdominal gas has a mechanical pathway to the retroperitoneum. CASE: Emphysema of the abdominal wall associated with volvulus developed after cesarean delivery. CONCLUSION: Postcesarean abdominal pathology may be associated with emphysema of the abdominal wall.

[Pharmacokinetics of antibiotics in inflamed and healthy lung tissue]. / Pharmakokinetik von Antibiotika in entzündetem und gesundem Lungengewebe.

The pharmacokinetic profile of antibiotics at the site of antiinfective action is one of the most important determinants of drug response, since it correlates the antimicrobial effect. Up to now, only limited information on the lung tissue pharmacokinetics of antibiotic agents has been available. The aim of in-vivo microdialysis is to measure antibiotic penetration into the extracellular space fluid of normal or pneumonic human lung parenchyma. The lung penetration of cefpirom in elective thoracic surgery and piperacillin in septic thoracic surgery, substances with low protein binding, was measured. Intra-, or postoperatively, respectively, microdialysis probes were inserted into normal or pneumonic lung tissue and into healthy skeletal muscle to obtain reference values. Serum and microdialysis samples were collected at 20-minute intervals for at last 8 hours. The intrapulmonary concentrations of the antibiotics exceeded the minimum inhibitory concentrations (MIC) for most relevant bacteria for 4-6 hours. The procedure was well tolerated by all patients and no adverse events or microdialysis-associated side effects were observed. This microdialysis technique enabled continuous tissue pharmacokinetic measurement of free, unbound anti-infective agents in the lung tissue, even in pneumonia.

Penetration of piperacillin and tazobactam into pneumonic human lung tissue measured by in vivo microdialysis.

OBJECTIVES: The pharmacokinetic profile of antibiotics at the site of anti-infective action is one of the most important determinants of drug response, since it correlates with antimicrobial effect. Up to now, only limited information on the lung tissue pharmacokinetics of antibiotic agents has been available. The aim of this study was to measure, using a new microdialysis-based approach, antibiotic penetration into the extracellular space fluid of pneumonic human lung parenchyma. PATIENTS AND METHODS: The lung penetration of a combination of piperacillin and tazobactam, substances with low protein binding, was determined in five patients suffering from pneumonia and metapneumonic pleural empyema. The condition was treated by decortication after lateral thoracotomy. Intra-, or post-operatively, respectively, two microdialysis probes were inserted into pneumonic lung tissue, and into healthy skeletal muscle to obtain reference values. Serum and microdialysis samples were collected at 20-min intervals for at last 8 h following i.v. administration of a single dose of 4 g piperacillin and 500 mg tazobactam. RESULTS: The mean free interstitial concentration profiles of piperacillin in infected lung tissue and serum showed a maximal tissue concentration (Cmax) of 176.0 +/- 105.0 mg l-1 and 326.0 +/- 60.6 mg l-1, respectively. The mean AUC (area under the curve) for infected lung tissue was 288.0 +/- 167.0 mg.h l-1 and for serum 470.0 +/- 142.0 mg.h l-1. There was a statistically significant difference between AUC (lung) and AUC (serum) (P = 0.018) as well as between AUC (lung) and AUC (muscle) (P = 0.043). The intrapulmonary concentrations of piperacillin and tazobactam exceeded the minimum inhibitory concentrations (MIC) for most relevant bacteria for 4-6 h. The procedure was well tolerated by all patients and no adverse events or microdialysis-associated side-effects were observed. CONCLUSION: This microdialysis technique enabled continuous tissue pharmacokinetic measurement of free, unbound anti-infective agents in the lung tissue of patients with pneumonia. The present data corroborate the use of piperacillin and tazobactam in the treatment of lung infections caused by extracellular bacteria and demonstrate the distribution of piperacillin and tazobactam in the interstitial space of pneumonic lung tissue.

Thoracoscopical water jet lavage in coagulated hemothorax.

We propose the use of a pulsatile high-speed irrigation device during video-assisted thoracoscopy for retained, in part coagulated hemothorax. Blood clots and membranes adhering to intrathoracic structures are easily removed by the water jet without damaging underlying structures. The efficient dilution of the sticky retained blood and the fragmented coagula enable their quick removal over a suction catheter.

Severe heart laceration in penetrating chest trauma: thoracoscopy as a key to diagnosis.

A patient had attempted suicide by firing a butcher's gun into his left chest 3 cm caudal to the mammilla. Transthoracic echocardiography and CT-scan showed a discrete hematopneumothorax but no pericardial effusion, the cardio respiratory condition was stable. As the bolt had been aimed directly at the heart of the patient, thoracoscopy was performed to rule out cardiac trauma. Thoracoscopy showed a distinct severe contusion of the otherwise intact pericardium and a hemopericardium. Immediate thoracotomy and pericardiotomy revealed significant intrapericardial bleeding caused by an incomplete rupture of the left ventricle. The condition was successfully treated by direct reinforced suture.

Comparison of 5-aminolaevulinic acid and porphyrin photosensitization for photodynamic therapy of malignant bronchial stenosis: a clinical pilot study.

BACKGROUND AND OBJECTIVES: Photosan, a mixture of porphyrin oligomers as sensitizer for photodynamic therapy (PDT), carry the risk of prolonged photosensitivity of the skin. New sensitizer such as 5-aminolaevulinic acid (ALA) with low rates of skin phototoxicity appear to be promising alternatives. The aim of this study was to evaluate the efficacy of ALA compared to Photosan for PDT in malignant tracheo-bronchial stenosis. Reduction of tumor stenosis, increase in quality of life, and phototoxicity were considered as primary objectives. Improvement in clinical symptoms due to reduction of tumor stenosis, for example hemotysis, dyspnea, and poststenotic pneumonia were considered as secondary objectives. PATIENTS AND METHODS: After diagnostic work-up, photosensitization was done in 16 patients with ALA (60 mg/kg BW, oral, 6-8 hours prior to PDT) and in 24 patients with Photosan (2 mg/kg BW, i.v., 48 hours before PDT). The light dose was calculated as 100 J/cm(2) tumor length. Light at 630 nm was applied using a pumped dye laser. In both groups, additional hyperbaric oxygenation was applied at a level of 2 absolute atmospheric pressure. RESULTS: Stenosis diameter and Karnofsky performance status showed a significant improvement in favor of the Photosan-group, P = 0.00073 and 0.00015, respectively. In both groups no sunburn occurred due to phototoxicity of the sensitizer. CONCLUSION: Despite the limitations of a non-randomized study, photosensitization with Photosan seems to be more effective in PDT of malignant tracheo-bronchial stenosis compared to ALA.