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R. G. Davies1, P. S. Myles1,2,3,* and J. M. Graham4
1Department of Anaesthesia and Pain Management, Alfred Hospital Commercial Road, Melbourne, Victoria 3004, Australia
2Academic Board of Anaesthesia and Perioperative Medicine, Monash University Victoria 3800, Australia
3Centre for Clinical Research Excellence Canberra, Australia
4Department of Anaesthesia, Austin Hospital Heidelberg, Australia

*Corresponding author: Department of Anaesthesia and Pain Management, The Alfred Hospital, PO Box 315, Melbourne, VIC, 3004, Australia. E-mail: p.myles@alfred.org.au

Epidural analgesia is considered by many to be the best method of pain relief after major surgery. It is used routinely in many thoracic surgery centres. Although effective, side-effects include hypotension, urinary retention, incomplete (or failed) block, and, in rare cases, paraplegia. Paravertebral block (PVB) is an alternative technique that may offer comparable analgesic effectiveness and a better side-effect profile. We undertook a systematic review and meta-analysis of all relevant randomized trials comparing PVB with epidural analgesia in thoracic surgery. Data were abstracted and verified by both authors. Studies were tested for heterogeneity, and meta-analyses were done with random effects or fixed effects models. Weighted mean difference (WMD) was used for numerical outcomes and odds ratio (OR) for dichotomous outcomes, both with 95% CI.

We identified 10 trials that had enrolled 520 thoracic surgery patients. All of the trials were small (n<130) and none were blinded. There was no significant difference between PVB and epidural groups for pain scores at 4–8, 24 or 48 h, WMD 0.37 (95% CI: –0.5, 121), 0.05 (–0.6, 0.7), –0.04 (–0.4, 0.3), respectively. Pulmonary complications occurred less often with PVB, OR 0.36 (0.14, 0.92). Urinary retention, OR 0.23 (0.10, 0.51), nausea and vomiting, OR 0.47 (0.24, 0.53), and hypotension, OR 0.23 (0.11, 0.48), were less common with PVB. Rates of failed block were lower in the PVB group, OR 0.28 (0.2, 0.6). PVB and epidural analgesia provide comparable pain relief after thoracic surgery, but PVB has a better side-effect profile and is associated with a reduction in pulmonary complications. PVB can be recommended for major thoracic surgery.

Authors
Schmid RA. Stammberger U. Hillinger S. Vogt PR. Amman FW. Russi EW. Weder W.
Institution
Department of Surgery, University Hospital, Zurich, Switzerland.
Title
Lung volume reduction surgery combined with cardiac interventions.
Source
European Journal of Cardio-Thoracic Surgery. 15(5):585-91, 1999 May.
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Abstract
OBJECTIVE: Postoperative course and functional outcome were evaluated in patients who underwent lung volume reduction surgery (LVRS) or in combination with valve replacement (VR), percutaneous transluminal coronary angioplasty (PTCA), placement of a stent, or coronary artery bypass grafting (CABG). METHODS: Patients with severe bronchial obstruction and hyperinflation due to pulmonary emphysema were evaluated for lung volume reduction surgery. Cardiac disorders were screened by history and physical examination and assessed by coronary angiography. Nine patients were accepted for LVRS in combination with an intervention for coronary artery disease (CAD). In addition, three patients with valve disease and severe emphysema were accepted for valve replacement (two aortic-, one mitral valve) only in combination with LVRS. Functional results over the first 6 months were analysed. RESULTS: Pulmonary function testing demonstrates a significant improvement in postoperative FEV1 in pa!
tients who underwent LVRS combined with an intervention for CAD. This was reflected in reduction of overinflation (residual volume/total lung capacity (RV/TLC)), and improvement in the 12-min walking distance and dyspnea. Median hospital stay was 15 days (10-33). One patient in the CAD group died due to pulmonary edema on day 2 postoperatively. One of the three patients who underwent valve replacement and LVRS died on day 14 postoperatively following intestinal infarction. Both survivors improved in pulmonary function, dyspnea score and exercise capacity. Complications in all 12 patients included pneumothorax (n = 2), hematothorax (n = 1) and urosepsis (n = 1). CONCLUSION: Functional improvement after LVRS in patients with CAD is equal to patients without CAD. Mortality in patients who underwent LVRS after PTCA or CABG was comparable to patients without CAD. LVRS enables valve replacement in selected patients with severe emphysema otherwise inoperable.

Title:Coronary artery bypass grafting in the conscious patient without endotracheal general anesthesia
Authors:Karagoz,H.Y.; Sonmez,B.; Bakkaloglu,B.
Journal : Annals of Thoracic Surgery 70: 91-6, 2000
BACKGROUND: Over the past several years, considerable experience has accumulated in performing coronary anastomoses on the beating heart, and various aspects of minimally invasive approaches have been simplified. In an attempt to further simplify and decrease the “invasiveness” of this procedure, performing this operation without endotracheal general anesthesia was deemed feasible in certain subsets of patients. METHODS: Between October 1998 and June 1999, 5 patients underwent coronary artery bypass grafting without endotracheal general anesthesia, using high thoracic epidural block to construct extension grafts with a short segment of radial artery, between the in situ left or right internal thoracic arteries and the left anterior descending (n = 4) or right coronary arteries (n = 1). There were 2 female and 3 male patients, with a mean age of 67.4 +/- 8.3 years. RESULTS: The perioperative course of the patients was uneventful. There was no perioperative morbidity or mortality. No patient was converted to general anesthesia or to conventional operation. Control angiograms revealed patent anastomoses in all patients. In 1 patient, spasm of the radial artery graft was observed that was relieved 3 weeks later spontaneously. Mean length of hospital stay was 2.2 +/- 0.4 days. All patients were symptom free and returned to normal daily life at the first postoperative month. CONCLUSIONS: Our initial experience confirms the feasibility of performing coronary bypass grafting in the conscious patient without endotracheal general anesthesia

Title:Efficacy and tolerance of a new silicone stent for the treatment of benign tracheal stenosis: preliminary results
Authors:Vergnon,J.M.; Costes,F.; Polio,J.C.
Journal: Chest 118: 422-6, 2000
Abstract:In inoperable patients with tracheal stenosis who are treated using silicone stents, stent migration occurs in 18.6% of cases. To decrease the migration rate, a new silicone stent with narrow central and larger distal parts is desribed. This study analyzes the stability and tolerance of this new stent. DESIGN: Preliminary prospective study conducted in two French university hospitals. PATIENTS: Thirteen inoperable patients with benign complex tracheal stenosis due to intubation or tracheotomy. INTERVENTIONS: Tracheal stent insertion was performed under general anesthesia with a rigid bronchoscope. The patients were followed up clinically up to stent removal, which was planned at 18 months. RESULTS: Stent insertion or removal was very simple and did not differ from other silicone stents. No migration occurred after a mean follow-up of 22.8 months. Minimal granuloma formation occurred in only one patient (7.7%). Sputum retention remained similar to that with other silicone stents and could be improved by a smoother internal wall. Stents have been removed in seven patients after a mean duration of 19.6 months, with a complete stenosis cure in four cases. CONCLUSION: This new stent combines the stability of the metallic stents and the tolerance and easy removal of straight silicone stents. This allows a prolonged use in order to obtain curative action

Author
Ciriaco P. Mazzone P. Canneto B. Zannini P
Institution
Division of Thoracic Surgery, University of Milan, Scientific Institute H.S. Raffaele, Via Olgettina 60, 20132, Milan, Italy
Title
Supraventricular arrhythmia following lung resection for non-small cell lung cancer and its treatment with amiodarone.
Source
European Journal of Cardio-Thoracic Surgery, 18(1):12-16, 2000 July 1.
Abstract
Objective: From January 1998 to February 1999, 160 patients undergoing lung resection for non-small cell lung cancer were studied to define factors that increase the risk of postoperative supraventricular arrhythmia (SA) and to assess the effectiveness of amiodarone as an antiarrhythmic drug. Methods: All patients were monitored intraoperatively and postoperatively up to day 3. Onset of SA was documented with ECG. Amiodarone was administered to those who developed SA with a loading dose of 5 mg/kg in 30 min and a maintenance dose of 15 mg/kg in 24 h. Results: Mean age was 64 years (range 27-83 years). There were nine wedge resections, six segmentectomies, 127 lobectomies and 18 pneumonectomies. Twenty-two patients (13%) had SA, all of which were atrial fibrillations. The incidence of supraventricular arrhythmia with pneumonectomy and lobectomy was 33 and 12%, respectively (P=0.02). None of the patients who had a minor resection developed SA. The peak incidence of onset of SA!
occurred on postoperative day 2 and lasted from 1 to 12 days (average 3.4 days). Sinus rhythm was achieved with amiodarone in 20 patients (90.9%) with no side effects. Two patients received electrical cardioversion because hemodynamically unstable. Mean preoperative pO(2) and pCO(2) were lower in patients with SA: pO(2) 80.8 vs. 85 mmHg (P=0.04); pCO(2) 35.5 vs. 38 mmHg (P=0.01). Patients with concomitant cardiopulmonary diseases presented an odds ratio for postoperative arrhythmia of 12.4 (confidence interval 4.5-34.1) (P<0.0001). Conclusion: Concomitant cardiopulmonary diseases, lower pO(2), pCO(2) and extent of surgery increase the risk of postoperative SA after lung resection for non-small cell lung cancer. Cardiac monitoring in patients at risk is recommended. Amiodarone was both safe and effective in establishing and maintaining sinus rhythm.

Authors
Dyszkiewicz W. Pawlak K. Gasiorowski L.
Institution
Department of Thoracic Surgery, K. Marcinkowski University of Medical Sciences, Ul. Szamarzewskiego 62, Poznan, Poland.
Title
Early post-pneumonectomy complications in the elderly.
Source
European Journal of Cardio-Thoracic Surgery. 17(3):246-50, 2000 Mar.
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Abstract
OBJECTIVE: The surgical treatment of non-small cell lung cancer (NSCLC) in elderly patients presents a serious challenge to thoracic surgeons. As there is considerable divergence of opinion about both the mortality and morbidity rates, it is important to set guidelines for proper patient selection. METHODS: Early post-operative complications in 42 patients aged over 70 years who had undergone pneumonectomy because of NSCLC (Group I) were analyzed. The control group (Group II) consisted of 48 patients, also aged over 70 years, but who had undergone lobectomy or wedge resections. In both groups, the pre-operative conditions and 30-day morbidity and mortality were evaluated. RESULTS: Postoperative complications occurred significantly more frequently in pneumonectomy patients (78.5%) than in Group II (58%). Transient or long-standing arrhythmias were noted in 20 patients (47.6%) from Group I and in 17 (35.4%) from Group II. Pulmonary complications occurred in 17 patients (40.4%)!
from Group I and 16 (33.3%) from Group II. The most important factors contributing to post-operative complications in pneumonectomy patients were performance status (WHO), chronic obstructive pulmonary disease (COPD) and elevated level of blood urea nitrogen (BUN). The highest impact on early mortality in pneumonectomy patients was exerted by COPD, arterial hypertension, formation of broncho-pleural fistula (BPF), the need for re-thoracotomy and high level of BUN. CONCLUSIONS: (1) Pneumonectomy in patients over the age of 70 carries a considerable risk of severe post-operative complications and death, when compared to patients with less extensive pulmonary resections. (2) Elderly patients with impaired Performance Status (WHO 2 or more) and co-existing arterial hypertension, COPD and elevated level of BUN should be considered for pneumonectomy very carefully and cautiously.

Author
Leonard IE. Myles PS
Institution
Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria.
Title
Target-controlled intravenous anaesthesia with bispectral index monitoring for thoracotomy in a patient with severely impaired left ventricular function.
Source
Anaesthesia & Intensive Care, 28(3):318-321, 2000 June.
Abstract
The anaesthetic management of an elderly patient with severely impaired left ventricular function undergoing thoracotomy and lobectomy is described. Total intravenous anaesthesia (TIVA) with remifentanil and target-controlled infusion of propofol titrated according to the bispectral index (BIS) was used, with thoracic epidural anaesthesia commenced at the end of surgery providing postoperative analgesia. Avoidance of intraoperative epidural local anaesthetics and careful titration and dose reduction of propofol using the BIS was associated with excellent haemodynamic stability. The rapid offset of action of remifentanil and low-dose propofol facilitated early recovery and tracheal extubation. The BIS was a valuable monitor in optimal titration of TIVA.

Title:Reexpansion pulmonary edema after VATS successfully treated with continuous positive airway pressure
Authors:Iqbal,M.; Multz,A.S.; Rossoff,L.J.; Lackner,R.P.
Journal: Annals of Thoracic Surgery 70:669-71, 2000
Abstract:Reexpansion pulmonary edema is a well-described complication of treatment for pleural effusion and pneumothorax. It is very rarely described in association with anesthesia and video-assisted thoracoscopic surgery. The etiology is unclear but several mechanisms have been proposed.A case of reexpansion pulmonary edema after video-assisted thoracoscopic surgery treated successfully with continuous positive airway pressure is described

Title: Variability of a Thoracic Paraveretbral Block: Are we ignoring the Endothoracic Fascia?
Authors: Karmakar MK,Chung DC
Journal:Reg Anesth Pain Med 25: 325-7,2000

Letter. The variability which is reported in the spread of local anesthetics in the paravertebral space may depend on whether the injection is superficial or deep to the endothoracic fascia which divides the paravertebral space into two compartments.Due to attachments of this fascia to ribs and the vertebral bodies, injection into the subendothoracic compartment would be expected to spread more easily to other dermatomes and contralaterally. The thinness of this fascia ( 250 um) would make it difficult to identify during either open or percutaneous paravertebral block.