Zentralblatt für Chirurgie
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Following surgical procedures in thoracic surgery a chest X-ray is routinely performed and its necessity is rarely questioned. However, there are differences in the time frame of such radiological procedures. Especially after minor procedures such as mediastinoscopy there is a wide variation from a chest X-ray immediately after surgical intervention to an image only on the following day. Also, in some hospitals patients undergo only clinical but no radiological examination. No recommendations are available in the literature. ⋯ There are only sparse data concerning postoperative chest X-rays in thoracic surgery patients. In a study on children and young adults undergoing a Nuss procedure routine radiological examination was substituted by clinical indication resulting in a lower rate of thoracic drain placement. A chest X-ray to document the location of the metal bar prior to discharge was felt to be sufficient. In patients undergoing cardiac procedures daily routine chest X-rays on the intensive care ward were replaced by on-demand X-ray in a study without any change in length of stay, readmission or mortality. The same was found for chest X-rays following drain removal in cardiac patients: routine radiological examination seems not to be indicated. As a consequence of our own observational study on mediastinoscopy we have discontinued postoperative X-ray as the patients are examined clinically. All other patients undergoing thoracic surgery procedures who are observed in the intensive care unit receive the first chest X-ray in the morning following surgery. Only if complete expansion of the lung is warranted (pleurodesis, pneumothorax) an X-ray is performed on the day of surgery.
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Randomized Controlled Trial Comparative Study
[Postoperative pain in the acute phase after surgery: VATS lobectomy vs. open lung resection - results of a prospective randomised trial].
Minimally invasive procedures, e.g. video-assisted thoracoscopic lobectomy, are less traumatic and thus one may expect a lower level of postoperative pain compared to open procedures. This assumption is supported by several studies/metaanalyses. However, confirmation by larger prospective randomised studies is lacking. In the present study we analysed 2 groups of patients with lobectomy for early-stage lung cancer performed by VATS or by antero-lateral thoracotomy. ⋯ Regardless of procedure (VATS vs. open) pain control can be achieved with an adequate analgetic regime. For VATS during the first days a lower amount of medication is required. The VATS group showed a higher proportion of patients with very low postoperative pain profile: patients with pain score always under 4 and patients without pain at certain points before the 10th postoperative day or at discharge.
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Video-assisted thoracic surgery (VATS) procedures might reduce operative stress by minimising operative trauma. However VATS, in particular VATS lobectomy, is still associated with moderate acute postoperative pain. A gold standard for regional analgesia for VATS procedures has not yet surfaced, the studies published so far are very heterogeneous. ⋯ Although thoracic epidural analgesia (TEA) may not have been shown to be superior to other analgesic regimens, it is undoubtedly efficient as an analgesic treatment. With the increasing popularity of VATS procedures, there is growing demand from both surgeons and anaesthesiologists for an evidence-based approach to pain management for these procedures. Further studies on this topic are crucial to establish guidelines for pain management in VATS procedures.
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The efficient and persisting treatment of the pain accompanying thoracic surgery is fundamental and beneficial for patients, since severe postoperative pulmonary complications and the incidence of chronic pain will be reduced. In this review the role of thoracic epidural analgesia in preventing and treating pain after thoracic surgery will be discussed critically and alternative strategies presented.
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The perioperative use of anticoagulants in general thoracic surgery can be considered to be a "two-edged sword": the goal to minimise the risk of a thromboembolic episode is contrary to the ongoing effort of the surgeon to minimise the risk of intra- and postoperative blood loss. Dispositional factors such as excessive tobacco use are common for thoracic surgery patients and often lead to cardiovascular comorbidity which necessitates the use of anticoagulants or antiplatelet drugs. ⋯ Unfortunately there are not enough existing data and published literature for evidence-based guidelines referring to the correct perioperative management for the new oral anticoagulants. Management algorithms are being recommended according to the multiple aspects of anticoagulant-treatment.