Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery.

The prevalence and severity of chronic pain after video-assisted thoracic surgery for pulmonary resection remains to be defined. Three hundred forty-three of 391 consecutive patients 3 to 31 months after pulmonary resection by lateral thoracotomy (n = 165) or video-assisted thoracic surgery (n = 178) responded to a questionnaire aimed at comparing the relative occurrence of chronic postoperative pain after video-assisted thoracic surgery and lateral thoracotomy approaches for pulmonary resection. Patients less than 1 year after operation (video-assisted thoracic surgery = 142; thoracotomy = 97) and more than 1 year after operation (video-assisted thoracic surgery = 36; thoracotomy = 68) were analyzed as individual cohorts. Chronic pain was assessed by questioning patients about the presence and the intensity of discomfort on the side of the operation (using a visual analog scale) and their need for analgesic medication and the presence of ongoing limitations in shoulder function. Patients who underwent video-assisted thoracic surgery (less than 1 year from operation) had less pain and subjective shoulder dysfunction although their pain medication requirements were similar to those of thoracotomy patients less than 1 year from operation. After 1 year, there was no significant difference in these "pain related" morbidity parameters between the two surgical approach groups (video-assisted thoracic surgery or thoracotomy).

Video Assisted Thoracic Surgery Study Group data.

The Video Assisted Thoracic Surgery Study Group was formed to collect data on thoracoscopic procedures in an effort to define the role for this new technique. With more than 40 participating institutions, 1,820 cases have been collected through December 1992. Lung nodules and pleural effusions represent the most frequent indications, and wedge resection and operation in the pleural space were the most common procedures performed. Four hundred thirty-nine procedures (24%) were converted to a thoracotomy because of the need for more extensive resection (219), inability to find the pathology (65), too large a lesion or difficult location (62), adhesions (58), equipment failure (25), or bleeding (10). Prolonged air leak (> 5 days) was the most frequent complication. Patients undergoing video-assisted thoracic surgery and wedge resection had a mean hospital stay of 5.1 days; video-assisted thoracic surgical lobectomy was performed in 38 patients, who had a mean stay of 6.3 days. Air leaks were more prevalent in patients with poor pulmonary function (forced expiratory volume in 1 second < 1 L) and the elderly (> or = 75 years) after video-assisted thoracic surgical wedge resection. Video-assisted thoracic surgery appears safe and may be advantageous for some procedures. Further studies will be required to define its precise role in thoracic surgery.

Cost analysis for thoracoscopy: thoracoscopic wedge resection.

Video-assisted thoracic surgery (VATS) procedures are now being performed with increasing frequency. The instrumentation and video equipment continue to evolve and much of this new technology is expensive. We reviewed our experience with VATS in our most recent 150 cases for the purpose of cost analysis. The costs incurred in patients undergoing VATS wedge resection for nodules (n = 45) were compared with those in similar patients having wedge resection using open techniques (n = 31). We found that patients who undergo open resections were more likely to spend time in the intensive care unit after surgery. The anesthesia costs were similar in the two groups. Disposable instrument costs were $623 higher for VATS resection; however, the operative time was shorter (101.4 minutes for VATS versus 122.5 minutes for the open procedure), making the total operating room costs comparable. The length of hospital stay was shorter after VATS resection (4.4 days for VATS versus 6.5 days for the open procedure), resulting in lower total hospital charges in the VATS group; however, this difference was not statistically significant. The cost of a VATS wedge resection for removing peripheral nodules is competitive with that of open techniques. Additional benefits, such as reduced pain, shorter operating times, and decreased hospital stays, make thoracoscopy a valuable diagnostic tool. The length of hospital stay, operating room time, disposable instrument costs, complications, and patient acuity all have an impact on the total costs and vary for different procedures. The operative time has shortened and the use of disposable instrumentation has lessened as our experience with thoracoscopy has increased.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of open versus thoracoscopic lung biopsy for diffuse infiltrative pulmonary disease.

BACKGROUND: Patients with diffuse pulmonary infiltrates often require biopsy for a diagnosis. Standard operative therapy, open wedge resection via thoracotomy, is associated with known morbidity. We hypothesized that closed thoracoscopic wedge resection may result in reduced morbidity and decreased duration of hospital stay. This retrospective study compares open resection with thoracoscopic wedge resection in patients with diffuse pulmonary infiltrates. METHODS: Seventy-five patients with diffuse pulmonary infiltrates underwent diagnostic lung biopsy. Patients requiring mechanical ventilation and high levels of pressure support before biopsy were excluded from the study. Between March 1987 and September 1991, a total of 28 patients underwent open wedge resection via lateral thoracotomy. Since April 1991, a total of 47 patients underwent thoracoscopic resection. RESULTS: There was no difference between the groups in age, sex, presence of immunosuppression, or final pathologic diagnosis. Adequate tissue was obtained for pathologic diagnosis in all patients of both groups. All surgeons believed that thoracoscopic biopsy provided better visualization of the entire lung than did a limited thoracotomy. Mean operative time was 69 minutes for open biopsies and 93 minutes for thoracoscopic biopsies [p = 0.038]. Mean duration of chest tube drainage was not significantly different between the two groups. Duration of hospital stay was significantly less for thoracoscopic biopsy (4.9 days) than for open biopsy (12.2 days) (p = 0.018). Fourteen of 28 open biopsies resulted in complications compared with 9 of 47 closed biopsies (p = 0.009). There were 6 deaths among patients having open biopsies and 3 deaths among those having closed biopsies (p = not significant). CONCLUSION: A significant decrease in hospital stay was noted with thoracoscopic biopsy when compared with lung biopsy via the standard open approaches. Thoracoscopy provided excellent visualization and allowed for wedge resection that provided adequate tissue for diagnosis in patients with diffuse pulmonary interstitial disease.

Residual intersegmental spinal mobility following limited pedicle fixation of thoracolumbar spine fractures with the fixateur interne.

The Fixateur Interne has been proposed for limited pedicle fixation of thoracolumbar spine fractures with the assumption that motion in the nontraumatized spinal segments could be maintained. To date, no data exist that both localize and quantitate spinal mobility about the fractured vertebra. Voluntary maximum lateral flexion and extension radiographs were obtained on patients with unstable thoracolumbar spine fractures at a minimum of 2 years after Fixateur Interne instrumentation (implant was removed after 1 year). Residual intersegmental motion was measured at levels adjacent to both the vertebra fracture and the fixation. Fifty-nine patients were reviewed, and the posterior vertebral body angle demonstrated a mean total sagittal motion of 2.98 degrees. Cephalad and caudal to the fractured vertebra, a mean of 1.34 degrees and 3.08 degrees, respectively, of residual motion was noted; cephalad and caudal to the previously instrumented segment a mean of 3.22 degrees and 6.88 degrees, respectively, was measured. The authors conclude that residual mobility is most evident at the caudal end of the instrumented segment, removed from the fractured vertebra. The level with end plate disruption becomes essentially ankylosed, with or without a fusion.