Pain control of thoracoscopic major pulmonary resection: is pre-emptive local bupivacaine injection able to replace the intravenous patient controlled analgesia?

Background

The aim of this open-label, non-inferiority trial was to evaluate whether pre-emptive local bupivacaine injection (PLBI) can replace intravenous patient controlled analgesia (IV PCA) in video-assisted thoracic surgery (VATS) major pulmonary resection.

Methods

A total of 86 patients scheduled for VATS segmentectomy/lobectomy were randomly assigned into two groups. The PLBI group (n=42) received 0.5% bupivacaine wound infiltration before skin incision, and the IV PCA group (n=44) received a continuous infusion of fentanyl with a basal rate of 10 µg/mL/h. Visual analogue scale (VAS; range, 0-10) was measured as the primary endpoint. The secondary endpoint was an additional use of analgesics and drug induced side effects.

Results

Both groups showed no difference in terms of age, sex, disease entity, operation time, chest tube indwelling time, and hospital stay. Serial pain scores between the PLBI and IV PCA groups demonstrated no statistical differences (non-inferiority margin; ΔVAS =1.0) (Recovery room: 8.3±2.1 vs. 8.5±1.7; Day 0: 5.1±1.6 vs. 5.2±1.4; Day 1: 3.5±1.6 vs. 3.3±1.2; Day 2: 2.7±1.3 vs. 2.5±1.2; Day 3: 2.3±1.3 vs. 2.1±1.5; 1 week after discharge: 3.0±1.7 vs. 2.8±1.5; 1 month: 1.9±1.2 vs. 2.3±1.4 and 2 months: 1.5±1.2 vs. 1.3±1.2; 95% confidential interval (CI) of ΔVAS <1.0; P>0.05). The mean one-additional usage of IV analgesics was needed in the PLBI group (3.3±2.1 vs. 2.3±1.3; P=0.03). The occurrence of nausea/vomiting was higher in the IV PCA group (12.5% vs. 38.9%; P=0.026) and 41.7% of IV PCA patients experienced drug side effects that required IV PCA removal within postoperative day (POD) 1.

Conclusions

PLBI is a simple, safe, effective, and economical method, which is not inferior to IV PCA in VATS major pulmonary resection.     

Thoracoscopic double sleeve lobectomy in 13 patients: a series report from multi-centers

Background

This study aims to explore the feasibility and safety of video-assisted thoracic surgery (VATS) double sleeve lobectomy in patients with non-small lung cell cancer (NSCLC).

Methods

Between June 2012 and August 2014, 13 NSCLC patients underwent thoracoscopic double sleeve lobectomy and mediastinal lymphadenectomy at three institutions. A retrospective analysis of clinical characteristics, operative data, postoperative events and follow-up was performed.

Results

Thirteen NSCLC patients (median age, 60 years; range, 43-67 years) underwent thoracoscopic double sleeve lobectomy. There were no conversions to thoracotomy. Left upper lobectomy was most frequently performed (eleven patients). Median operative time was 263 minutes (range, 218-330 minutes), and median blood loss was 224 mL (range, 60-400 mL). The learning curve revealed reductions in both operative times and blood loss of ten cases from one center. Median data were duration of blocking pulmonary artery (PA) 72 minutes (range, 44-143 minutes), resected lymph nodes 24 (range, 10-46), stations of retrieved lymph nodes 6 (range, 5-9), thoracic drainage 1,042 mL (range, 500-1,700 mL), duration of thoracic drainage 5 days (range, 3-8 days), postoperative hospital stay 10 days (range, 7-20 days), and ICU stay 1 day (range, 1-2 days). One patient (1/13, 7.70%) suffered from pneumonia after surgery. There were no deaths at 30 days. Median duration of follow-up was 6 months (range, 1-26 months). And no local recurrences or distant metastasis were reported.

Conclusions

Thoracoscopic double sleeve lobectomy is a technically challenging, but feasible procedure for NSCLC patients and it should be restricted to skilled VATS surgeons.     

Congenital cystic lesions of lung in the paediatric population: A 5-year single institutional study with review of literature

Background:

The aim was to evaluate the clinical presentation, investigation modalities, operative management, pathology, outcome (morbidity and mortality) and short term follow-up of congenital cystic lesions of the lung.

Materials and Methods:

This is a retrospective study. Study period was 5 years (December 2008-November 2013) in the Department of paediatric surgery, Nil Ratan Sircar Medical College. Study population: Total number = 10 patients. Age range: 2 days-7 years. (Neonate-4). Male and female ratio = 1:1.

Result:

Among 10 cases of lung cyst four having congenital lobar emphysema, four having congenital pulmonary airway malformation, one sequestration and one teratoma. All patients have undergone surgical excision in terms of lobectomy or excision of the lesion. Post-operative histopathology confirmed the diagnosis. Recovery was uneventful.

Conclusion:

Although our experience is limited, operative management of lung cysts seems to be safe with rewarding results. However we are yet to encounter many of the other varieties of the cysts found in the lung, which may be associated with other congenital anomalies and have an impact on prognosis.     

以心指数/每搏指数/每搏量变异度为导向的老年患者开胸肺叶切除术液体管理的临床研究

目的 观察以心指数/每搏指数/每搏量变异度(cardiac index/stroke volume index/stroke volume variation,CI/SVI/SVV)为导向的液体管理策略对行开胸肺叶切除术的老年患者术后转归的影响.方法 30例行择期肺叶切除术的患者,年龄≥65岁,美国麻醉医师协会(ASA)分级Ⅰ～Ⅱ级,采用随机数字表法随机分为以CI/SVI/SVV为导向的S组(15例)和以中心静脉压(central venous pressure,CVP)为导向的C组(15例),监测围术期两组指标,包括心率(heart rate,HR)、平均动脉压(mean arterial pressure,MAP)、动脉血氧饱和度(arterial oxygen saturation,SpO2)、呼气末二氧化碳分压(end-tidal carbon dioxide partial pressure,PETCO2)、气道压力(airway pressure,Pmax)、脑电双频指数(bispectral index,BIS)等,评价以CI/SVI/SVV为导向的围术期液体管理策略在改善患者术后转归方面是否优于传统的以CVP为指导的液体管理策略. 结果 S组患者术中不同观察时间点HR、MAP、SpO2、PETCO2、Pmax、BIS与C组比较差异无统计学意义.S组患者术中输液量(1 310±310) ml、术后液体输入的正平衡量(516±412) ml明显小于C组患者(1 820±459)、(757±667) ml(P＜0.05),术后重症监护室(ICU)驻留时间、氧合指数等指标S组较C组呈现良好的转归趋势.C组患者术后高血压的发生率(40％)明显高于S组(6.67％)(P＜0.05),余无特殊.结论 以CI/SVI/SVV为导向的老年胸科手术围术期液体管理策略较传统的以CVP为导向的液体管理具有创伤小、操作简便、液体管理更具个性化等优点,有助于改善老年患者术后转归.     

支气管肺动脉成形术治疗老年ⅢA期中央型肺癌患者的临床分析

目的探讨支气管肺动脉成形术治疗中央型肺癌的临床价值。方法选取我院48例中央型肺癌患者,随机分为治疗组和对照组,31例行支气管肺动脉成形术,17例行全肺切除术。比较两组术后并发症的发生率、1、3、5年生存率及术后5年生存患者的生活质量。结果两组围手术期无死亡病例。治疗组术后并发症的发生率为9.69%,对照组术后并发症的发生率为29.40%。治疗组1、3、5年生存率77.42%、48.39%和29.03%,对照组1、3、5年生存率70.58%、41.17%、23.52%。术后并发症及生存率差异无统计学意义(P>0.05)。治疗组与对照组的生存质量评分差异有统计学意义(P<0.05)。结论支气管肺动脉成形术较全肺切除术术后并发症及生存率无明显差异,但术后生存质量明显较高。     

全胸腔镜肺叶切除治疗早期肺癌22例临床报道

目的 探讨全胸腔镜下肺叶切除治疗早期肺癌的临床疗效.方法 分析我院胸外科施行的22例早期非小细胞肺癌全胸腔镜下肺叶切除术+淋巴结清扫患者资料.结果 22例患者均顺利完成手术,无手术死亡及术后重大并发症.术中中转开胸2例,术后引流量150～450 ml,平均260 ml,术中失血量平均190 ml,平均住院日12天,手术中淋巴结清扫4～16个,平均10.5个,回访所有患者均生存良好.结论 全胸腔镜下肺叶切除术是一种安全、有效、微创的手术方式,对于Ⅰ～Ⅱ期非小细胞肺癌患者是合适的.     

超声引导下前锯肌平面阻滞对胸腔镜下肺叶切除术患者术后镇痛的影响

目的 探讨超声引导下前锯肌平面阻滞 （SAPB） 对胸腔镜下肺叶切除术患者术后镇痛效果的影响。方法 60例择期全麻下行胸腔镜下肺叶切除术患者随机分为静脉自控镇痛组 （P组） 及静脉自控镇痛+SAPB组 （S组） 2组术毕均行吗啡静脉自控镇痛 （PCIA）, S组患者手术结束后立即行超声引导下术侧SAPB, 注射0.375%罗哌卡因 0.4 mL/kg。记录2组患者术后6 h、 12 h、 24 h内吗啡累积消耗量及术后30 min、 1 h 、 2 h、 6 h、 12 h、 24 h NRS疼痛评分若NRS疼痛评分大于4分, 静脉注射氟比洛芬酯50 mg, 必要时可重复, 并记录镇痛补救比例、 术后RASS镇静评分以及恶心呕吐、 瘙痒、 呼吸抑制、 心动过缓、 低血压等不良反应发生情况。结果 S组术后30 min、 1 h 、 2 h、 6 h NRS疼痛评分明显低于P组 （P＜0.01）, 2组术后12 h及24 h NRS疼痛评分差异无统计学意义; 2组NRS疼痛评分均随着术后时间的延长逐渐降低, 处理因素与时间因素不存在交互作用 （P＞0.05）; S组术后6、 12、 24 h内吗啡累积消耗量均明显低于P组 （P＜0.01）; 2组不良反应发生率, 以及组间的RASS镇静评分, 镇痛补救比例差异无统计学意义。结论 超声引导下SAPB能明显减少胸腔镜下肺叶切除术患者术后吗啡消耗量及减轻术后早期疼痛, 且不增加不良反应。     

Surgical techniques and outcome analysis of uniportal video-assisted thoracic surgery complex sleeve lung resection: a 20 case-series study

BackgroundOur study aims to explore the feasibility of uniportal video-assisted complex sleeve lung resection and summarize the surgical techniques and clinical outcomes.MethodsFrom June 2016 to April 2020, a total of 20 complex sleeve pulmonary and distal tracheal resections were performed by the single surgical team at the Thoracic Surgery Department of the Shanghai Pulmonary Hospital. We defined cases as complex sleeve pulmonary resections if they required pulmonary segment sleeve resection, extended sleeve resection (lobectomy plus segmentectomy of the remaining lobe), sleeve pneumonectomy, lobectomy plus carinoplasty or neo-carina construction, pulmonary-sparing main bronchus resection plus carina reconstruction, and distal trachea resection with end to end anastomosis.ResultsThe 20 cases comprised lung squamous cell carcinoma (n=11), lung adenocarcinoma (n=2), hamartoma (n=3), adenoid cystic carcinoma (n=2), carcinoid tumor (n=1), and pleomorphic carcinoma (n=1). The average blood loss during the operation was 250±126.17 mL (50–800 mL). The average operation time was 192.0±61.1 minutes. The average number of lymph node stations removed was 5.82±1.33, including station seven in all cases, and the median number of lymph nodes removed was 4.18±5.89. On the day of surgery, the drainage volume was 266±192.01 mL. The mean postoperative hospital stay was 5.37±1.86 days. Twelve of the 16 patients diagnosed with malignancy received postoperative chemotherapy. Granuloma formation at the anastomosis level led to stenosis in one case, and tumor recurrence occurred in one case. Broncho-esophageal fistula occurred in one patient after radiochemotherapy. The postoperative follow-up time was 15.6±10.7 months. The 30-day mortality was zero, and at one-year follow-up, only one patient had died of metastatic disease after the operation.ConclusionsUniportal video-assisted complex sleeve pulmonary resections are feasible when conducted by experienced teams.     

腹腔镜左肝外叶切除+胆道镜取石术治疗左肝内胆管结石的临床研究

目的 :探讨腹腔镜左肝外叶切除+胆道镜取石术治疗左肝内胆管结石的临床效果.方法 :根据不同术式将89例左肝内胆管结石患者分为观察组与对照组,观察组采取腹腔镜左肝外叶切除+胆道镜取石术治疗,对照组行开腹左肝外叶切除术+胆道镜取石术,比较两组临床疗效.结果 :两组结石残留率及随访1年结石复发率比较差异无统计学意义;观察组平均术后下床活动时间、肠功能恢复时间及住院时间较对照组显著短;观察组并发症总发生率为17.78%显著低于对照组的36.36%,差异有统计学意义.结论 :腹腔镜左肝外叶切除+胆道镜取石术与开腹左肝外叶切除术+胆道镜取石术治疗左肝内胆管结石在术后结石残留、结石复发减少方面效果类似,但腹腔镜联合术式术后胃肠功能恢复快,并发症明显少,更安全,可作为左肝内胆管结石治疗的重要术式之一.     

Isolated caudate lobectomy: Left-sided approach. Case reports

IntroductionThe caudate lobe is a distinct liver lobe and surgical resection requires expertise and precise anatomic knowledge. Left-sided approach was described for resection of small tumors originated in the Spiegel lobe but now the procedure has been performed even for tumors more than five centimeters. The aim of this study is to present three cases of tumor of caudate lobe underwent isolated lobectomy by left-sided approach.Presentation of caseThree patients with metastasis of colorectal cancer, carcinoma hepatocellular and metastasis of neuroendocrine tumor underwent resection. After modified Makuuchi incision, early control of short hepatic e short portal veins before hepatectomy was performed. The operative time was 200, 270 and 230 min respectively. No blood transfusion was used and no postoperative complications were observed. The length of stay was 7, 11 and 5 days respectively.DiscussionSome approaches have been described to access and resect tumors of the caudate lobe, including the left-sided approach, right-sided approach, combined left- and right-sided approach and the anterior transhepatic approach. For liver resection in patients with malignant disease, parenchymal preservation is important in order to avoid postoperative liver failure or due to the risk of second hepatectomy. In these patients isolated caudate lobectomy is a safe option.ConclusionIsolated caudate lobectomy is a feasible procedure. Left-sided approach can be preformed even for tumors larger than 5 cm.