Does Enhanced Recovery After Surgery Protocols Reduce Complications and Length of Stay After Thoracic Surgery: A Systematic Review of the Literature.

Enhanced recovery after surgery (ERAS) has an increasingly important role in the perioperative management of thoracic surgical patients. It has been extensively studied in multiple surgical specialties, particularly colorectal surgery, where ERAS protocols have been shown to reduce postoperative length of stay and postoperative complications. Electronic searches of two research databases were performed: PubMed (1972 to October 2023) and Ovid MEDLINE (1946 to October 2023). The literature search was completed on January 4, 2024. Search terms included: "thoracic surgery" and "ERAS" or "Enhanced Recovery After Surgery". The search was limited to studies evaluating humans undergoing thoracic surgery for any indication. The primary outcome was overall morbidity, with secondary outcomes including mortality, length of stay, and pulmonary complications. The search yielded a total of 794 records, of which 30 (four meta-analyses and 26 observational trials) met the relevant inclusion and exclusion criteria. This review suggested the implementation of ERAS protocols can lead to a reduction in postoperative morbidity; however, this was not a consistent finding. The majority of studies included demonstrated a reduction in the length of stay with the implementation of ERAS. Overall, ERAS/ERATS is an important adjunct to the management of patients requiring thoracic surgery, consistently leading to shorter lengths of stay and likely contributing to reduced rates of postoperative morbidity. Further research will be required to determine the impact of the recently released ERATS guidelines.

Primary Pulmonary Echinococcosis in the United States: A Case Report and Review of the Literature.

We depict a unique case of a 34-year-old woman who presents to the emergency department with complaints of dyspnea and chest pain for the past month. A chest x-ray (CXR) from an earlier urgent care visit was concerning for large fluid opacity in the left lung and follow-up imaging revealed a cystic mass suspicious of a pulmonary cystic abscess. The patient underwent complete lobectomy and resection. Post-surgical biopsy confirmed pulmonary hydatid cystic mass and signs of rupture or seeding to liver tissue. The patient was discharged with adjuvant therapy and recommended imaging follow-up for the next decade. The diagnosis, treatment, and maintenance guidelines are discussed in this report which reveals controversy between experts given the lack of complete literature regarding echinococcosis. Our purpose in putting forward this case is to present a rare diagnosis of pulmonary echinococcosis in the United States and to emphasize the importance of early imaging and diagnosis to prevent cystic rupture and secondary organ dissemination.

Utilizing the visual analogue scale (VAS) to monitor and manage pain in post-operative skin wounds after thoracic surgery.

Due to the global increase in thoracic interventions, there is greater emphasis on refining post-operative care. The purpose of this study was to validate the visual analogue scale (VAS) as the valid method for measuring post-operative pain in thoracic surgery patients. From January 2020 to June 2022, this cross-sectional study investigated 240 adult patients who underwent elective thoracic surgeries in Thoracic Surgery Department of Heilongjiang Provincial Hospital. The participants were instructed to rate their discomfort using VAS at predetermined intervals after surgery. The following demographic and clinical information was recorded: age, gender, type of thoracic surgery, and history of chronic pain. Results showed a progressive decline in post-operative VAS scores over 72 h: 8.2 immediately after surgery, 6.0 at 24 h, 5.4 at 48 h, and 3.6 by 72 h. There were notable correlations between VAS scores and chronic pain history, with moderately positive correlation of 0.40 being observed. Mean scores for males and females were 3.8 and 3.9, respectively. The analysis by age revealed comparable mean scores for age categories below and above 40. With the exception of thoracic wall resection, which resulted in an average VAS score of 4.1 ± 1.0 (p < 0.05), the type of surgery had the minimal effect on variability of pain scores. The VAS is a reliable method for evaluating post-thoracic surgery discomfort. Given the substantial impact of pain history on VAS scores, there is an urgent need for personalized pain management strategies to improve post-operative care.

Study of the Relative Frequency of Spontaneous Pneumothorax Recurrence with Two Policy Therapies: A Clinical Trial.

Background: Spontaneous pneumothorax is a potentially fatal condition with a high risk of recurrence. The purpose of this study is to compare two different approaches to SP management. In the first group, patients underwent only chemical pleurodesis; in the second group, CT-scan, VATS, and then chemical pleurodesis was performed. Materials and Methods: This study is a non-randomized clinical trial conducted on 65 patients admitted to Al-Zahra Hospital in Isfahan with a primary complaint of sudden dyspnea and a definitive diagnosis of spontaneous pneumothorax. Two studies compared the main outcomes of recurrence within six months and the time until recurrence. Results: Age, sex, and BMI were matched between the two study groups. The side of the pneumothorax, smoking history, and pulmonary disease history did not differ significantly (P > 0.05). Pneumothorax recurrence did not differ significantly between the two groups (P: 0.477). Conclusion: This study demonstrated no distinction between VATS and chemical pleurodesis when using only chemical pleurodesis. However, because numerous studies have suggested that one of these techniques may be beneficial for patients with SP, it is recommended to conduct additional randomized controlled trials (RCTs) with a more detailed plan and more comparable procedures, although it appears that meta-analysis design may be effective given the abundance of available RCT studies.

Intensity of one-lung ventilation and postoperative respiratory failure: A hospital registry study.

BACKGROUND: Studies linked a high intensity of mechanical ventilation, measured as high mechanical power (MP) to postoperative respiratory failure (PRF) in the setting of two-lung ventilation. We investigated whether a higher MP during one-lung ventilation (OLV) is associated with PRF. METHODS: In this registry-based study, adult patients who underwent general anesthesia with OLV for thoracic surgeries between 2006 and 2020 at a New England tertiary healthcare network were included. The association between MP during OLV and PRF (emergency non-invasive ventilation or reintubation within seven days) was assessed in a cohort weighted through a generalized propensity score conditional on a priori defined preoperative and intraoperative factors. Dominance of components of MP and intensity of OLV versus two-lung ventilation in predicting PRF was investigated. RESULTS: Out of 878 included patients, 106 (12.1%) developed PRF. The median (IQR) MP during OLV was 9.8 J/min (7.5-11.8) and 8.3 J/min (6.6-10.2) in patients with and without PRF respectively. A higher MP during OLV was associated with PRF (ORadj 1.22 per 1 J/min increase; 95%CI 1.13-1.31; p < 0.001) and characterized by a U-shaped dose-response curve, with the lowest probability of PRF (7.5%) at 6.4 J/min. Dominance analysis of PRF predictors showed a stronger contribution of driving pressure over respiratory rate and tidal volume, the dynamic over the static component of MP, and MP during OLV over two-lung ventilation (contribution to Pseudo-R2: 0.017, 0.021, and 0.036, respectively). CONCLUSION: A higher intensity of OLV, mainly driven by driving pressure, is dose-dependently associated with PRF and might constitute a target for mechanical ventilation.

A Non-Fatal Impalement Injury to the Right Thorax: A Case Report.

Impalement injuries secondary to motor vehicle collisions are rare. Reviewing the systematic approach to treating these injuries can benefit the surgical community. This case report discusses the presentation and management of a 32-year-old male who was involved in a high-speed, roll-over motor vehicle collision. The car struck a chain-link fence, and the unrestrained passenger sustained a fence post impalement injury to his right thorax. He was alert and oriented when emergency services arrived. He was extricated rapidly and transported to our level-one trauma center, where he received definitive operative management. The patient survived the injury and was discharged home. This case highlights key points in the systematic approach to impalement injuries, including minimal handling of the impaled object, expedient transfer to the local trauma center, emergent operative intervention, vascular control prior to removal of the foreign object, and aggressive irrigation and debridement of the wound.

Massive hemoptysis managed by prolonged anticoagulation-free veno-venous extracorporeal membrane oxygenation with which thoracic surgeries were accompanied: a case report.

BACKGROUND: Massive hemoptysis causing inadequate ventilation results in life-threatening consequences. We present a patient who developed respiratory insufficiency produced by bronchiectatic massive hemoptysis and underwent prolonged anticoagulation-free veno-venous extracorporeal membrane oxygenation (VV-ECMO) during which thoracic surgeries were performed. CASE PRESENTATION: A 79-year-old woman suffered massive hemoptysis resulting in respiratory failure during fiberoptic bronchoscopy. Bronchial intubation followed by one lung ventilation failed to ensure adequate oxygenation. Anticoagulation-free VV-ECMO, therefore, was installed immediately. Since conservative hemostatic measures including bronchial arterial embolization were not effective, resection of the culprit lung was performed while on VV-ECMO. Next day an exploratory thoracotomy and intercostal artery embolization were needed for recurrent bleeding. The VV-ECMO was withdrawn after five days of operation. CONCLUSIONS: Massive hemoptysis can be fatal and needs instantaneous and intensive treatments. In our case, long-term anticoagulation-free VV-ECMO during which thoracic surgeries and endovascular interventions were performed provided a favorable outcome.

Inhalational versus intravenous anesthetics during one lung ventilation in elective thoracic surgeries: A narrative review.

The anesthesia regimen used during one lung ventilation (OLV) carry the potential to affect intra-operative course and post-operative outcomes, by its effects on pulmonary vasculature and alveolar inflammation. This narrative review aims to understand the pathophysiology of acute lung injury during one lung ventilation, and to study the effects of inhalational versus intravenous anaesthetics on intraoperative and post-operative outcomes, following thoracic surgery. For this purpose, we independently searched 'PubMed', 'Google Scholar' and 'Cochrane Central' databases to find out randomized controlled trials (RCTs), in English language, which compared the effects of intravenous versus inhalational anaesthetics on intraoperative and post-operative outcomes, in elective thoracic surgeries, in human beings. In total, 38 RCTs were included in this review. Salient results of the review are- Propofol reduced intraoperative shunt and maintained better intraoperative oxygenation than inhalational agents. However, use of modern inhalational anaesthetics during OLV reduced alveolar inflammation significantly, as compared to propofol. Regarding post-operative complications, the evidence is not conclusive enough but slightly in favour of inhalational anaesthetics. Thus, we conclude that modern inhalational anaesthetics, by their virtue of better anti-inflammatory properties, exhibit lung protective effects and hence, seem to be safe for maintenance of anesthesia during OLV in elective thoracic surgeries. Further research is required to establish the safety of these agents with respect to long term post-operative outcomes like cancer recurrence.

Efficacy of Dexmedetomidine Versus Morphine as an Adjunct to Bupivacaine in Caudal Anesthesia for Pediatric Thoracic Surgeries: A Randomized Controlled Trial.

BACKGROUND: Caudal anesthesia is an effective method of pain management, which can be successfully employed to minimize post-thoracotomy pain in pediatric patients. However, its main disadvantage is the short postoperative analgesic period, which can be prolonged by the concurrent administration of one of many adjuvants. OBJECTIVES: This prospective randomized, blinded study aimed to compare the efficacy of dexmedetomidine versus morphine as adjuvants to bupivacaine in caudal anesthesia for thoracic surgeries in pediatric patients. METHODS: Fifty patients were randomly allocated into two equal groups. To achieve caudal epidural block anesthesia, the patients in group M (n = 25) were administered morphine and bupivacaine, while group D (n = 25) received a mixture of dexmedetomidine and bupivacaine. The primary outcome of this study was the postoperative analgesic duration achieved. The secondary outcomes included morphine administration in the first 24 hours following caudal block anesthesia, the face, legs, activity, cry, consolability (FLACC) scale scores, and adverse effects, including vomiting, itching, bradycardia, hypotension, and respiratory depression. RESULTS: The results showed that patients who had received dexmedetomidine achieved a longer postoperative analgesia as compared to those who had received morphine (P < 0.001). Postoperatively, the heart rate, blood pressure, pain score, and mean consumption of morphine were lower in group D as compared to the group M. There was no significant difference in the adverse effects between the two groups. CONCLUSIONS: The use of dexmedetomidine as an adjuvant to bupivacaine for caudal anesthesia during pediatric thoracic surgeries induced better and prolonged postoperative analgesia as compared to morphine.

Effect of aminophylline on the related indexes in perioperative period in thoracic surgery / 中国生化药物杂志

Objective To investigate the therapeutic effect of aminophylline on the treatment of patients with thoracic surgery perioperative. Methods 230 cases with thoracic surgery were selected as the research objects and divided into the research group and the control group randomly, and there was 15 cases in each group. the control group were ginven closed drainage of thoracic cavity during the surgery, continued to 3 days after surgery. The control group were given intravenous drip of ciprofloxacin lactate injection at 12 h after operation, and the treatment lasted for 7 days. At this basis, the research group were given aminophylline 0.5 mg/d by intravenous injection at the beginning of anesthesia induction and continued for 3 days. The levels of lung and respiratory inflammation related factor (White blood cells, PCT, hs-CRP, TNF-α, IL-6, IL-8 and IL-10), blood gas index in the two groups pre- and post–surgery were detected, and the complications and adverse drug reactions were observed. Results 24h after surgery, TNF alpha, IL-6, IL-8 were significantly lower than those in the control group (P<0.05), and IL-10 level was significantly higher than that in the control group (P<0.05). And PaO2 in the research groupwas significantly higher than that in the control group patients (P<0.05). After treatment, arterial carbon dioxide partial pressure (PaCO2) in the two groups were significantly lower than preoperative (P<0.05). The complication rate in the research group was significantly lower than that in the control group within ten days(P<0.05). There were no adverse reactions in both groups. Conclusion During the perioperative period in thoracic surgery, aminophylline intervention can effectively improve the prognosis. .

A retrospective study of open thoracotomies versus thoracoscopic surgeries for persistent postthoracotomy pain.

OBJECTIVE: Persistent thoracotomy pain syndrome (PTPS) is a recognized complication and is considered to be less after video-assisted thoracoscopic surgery (VATS) compared with open thoracic surgery (OTS). The primary objective was to compare the incidence of PTPS at 6 months. Secondary objectives were to compare the incidence of neuropathic pain between VATS and OTS and to report perioperative factors associated with the development of PTPS. METHODS: This historical cohort study involved patient contact by a questionnaire regarding the presence of PTPS and its type. Patient, surgical, and analgesia factors were collected from health records, acute pain, and thoracic surgery databases. The data were analyzed using a multivariable logistic regression analysis, with results reported as adjusted odds ratio (OR) (95% confidence interval; P value). RESULTS: Of 308 patients, 130 returned their questionnaire, and 106 responses were analyzed. The incidence of PTPS was 35% and 54% with VATS and OTS respectively, with an adjusted OR, 0.33 (95% confidence interval, 0.13-0.86), P= .024. The percentage of neuropathic pain was 18% and 48%, with VATS and OTS respectively, with an adjusted OR, 0.18 (0.04-0.85), P= .031. The diagnosis of cancer and previous chronic pain history were observed to be significantly associated with PTPS. CONCLUSIONS: Our study indicates that PTPS is significantly more common and has a higher chance of being neuropathic with OTS. Despite being relatively less traumatic, VATS still carries a significant potential for PTPS. A diagnosis of cancer and history of previous pain are highly predictive of its development.

Incidence of and risk factors for cardiovascular complications after thoracic surgery for noncancerous lesions.

OBJECTIVE: The purpose of this study was to determine the incidence of and risk factors for cardiovascular complications after thoracic surgery for noncancerous lesions. DESIGN: Retrospective cohort study. SETTING: A tertiary medical center. PARTICIPANTS: All consecutive patients undergoing either thoracotomy or thoracoscopy for noncancerous lesions between 2005 and 2011 were included. MEASUREMENTS AND MAIN RESULTS: The primary outcomes were the incidence and types of cardiovascular complications such as cardiac arrhythmias, cardiac arrest, heart failure, and myocardial ischemia during hospitalization. A total of 719 patients were recruited, 60% of whom had infections. The incidence of cardiovascular complications after thoracic surgery was 6.7% (48 of 719), of which cardiac arrhythmia was the most common (25 of 48, 52%). The multivariate risk regression analysis showed that age>55 years (risk ratio [RR]=4.0; 95% confidence interval [CI]=2.1-7.5; p<0.01), diabetes mellitus (RR=3.0; 95% CI=1.7-5.3; p<0.01), coronary artery disease (RR=4.8; 95% CI=2.3-10.2; p<0.01), duration of surgery>180 minutes (RR=2.6; 95% CI=1.3-5.1; p<0.01), intraoperative hypotension (RR=2.6; 95% CI=1.6-4.3; p<0.01), and positive fluid balance>2,000 mL (RR=2.5; 95% CI=1.4-4.5; p<0.01) were independent risk factors for cardiovascular complications. CONCLUSIONS: Knowledge of risk factors could help surgical teams to identify high risk patients and adjust modifiable risk factors including optimization of medical conditions, correction of intraoperative hypotension, and appropriate blood and fluid administration in order to reduce perioperative morbidity and mortality.