Edwin Lafontaine

Gabapentin does not reduce post-thoracotomy shoulder pain: a randomized, double-blind placebo-controlled study.

Purpose: Despite adequate epidural analgesia, up to 97% of patients undergoing thoracotomy experience ipsilateral shoulder pain. In this setting, this study evaluated the safety and the efficacy of pre-emptive gabapentin.Methods: A double-blind, placebo-controlled study was undertaken in 51 patients randomized into two groups. Two hours before surgery, 23 patients received gabapentin 1200 mgpo (Group G), and 28 patients received placebo (Group P). Shoulder pain and postoperative pain, at the surgical site, were monitored every four hours for 24 hr, using a numerical rating scale. Subcutaneous hydromorphone was administered for rescue analgesia against shoulder pain.Results: Forty-four patients complained of shoulder pain (prevalence of 86%). Demographic and surgical data were similar between the two groups. There were no significant differences in the total cumulative doses of hydromorphone administered at eight, 16, and 24 hr, nor were there differences in individual numerical rating scale scores for shoulder pain. The groups were similar with respect to the degree of pain at the surgical site. The frequency of side effects between groups at corresponding time intervals was also similar, with the exception of sedation. At four hours, the incidence of sedation scores τ; 1 was greater in Group G (21/23 patients), compared to Group P (18/28 patients;P=0.025). In contrast, by 24 hr, 5/18 patients in Group P had sedation scores τ;1, compared to 0/28 patients in Group G (P=0.05).Conclusion: Pre-emptively administered gabapentin, 1200 mg, does not reduce the incidence, or the severity, of post-thoracotomy shoulder pain in patients receiving thoracic epidural analgesia.RésuméObjectif: Malgré une analgésie péridurale adaptée, jusqu’à 97. % des patients subissant une thoracotomie éprouvent de la douleur à l’épaule ipsilatérale. Dans ce contexte, notre étude a évalué l’innocuité et l’efficacité de la gabapentine administrée de façon préventive.Méthode: Une étude à double insu et contrôlée par placebo a été menée ; elle évaluait 51 patients randomisés en deux groupes. Deux heures avant la chirurgie, 23 patients ont reçu de la gabapentine 1200 mg oralement (groupe G) et 28 un placebo (groupe P). La douleur à l’épaule et la douleur postopératoire au site chirurgical ont été évaluées toutes les quatre heures durant 24 h à l’aide d’une échelle d’évaluation numérique. De l’hydromorphone souscutanée a été administrée en analgésie de secours contre la douleur à l’épaule.Résultats: Quarante-quatre patients se sont plaints de douleur à l’épaule (prévalence de 86 %). Les données démographiques et chirurgicales étaient semblables dans les deux groupes. Il n’y a pas eu de différence significative dans les doses cumulatives totales d’hydromorphone administrée à huit, seize et 24 h, ni dans les scores individuels sur l’échelle d’évaluation numérique pour la douleur à l’épaule. Les groupes ont présenté des résultats semblables concernant le degré de douleur au site chirurgical. La fréquence des effets secondaires, comparée entre les groupes à des intervalles correspondants, était également similaire, à l’exception de la sédation. À quatre heures, l’incidence de scores de sédation τ;1 était plus élevée dans le groupe G (21/23 patients), comparé au groupe P (18/28 patients; P=0,025). En revanche, à 24 heures, 5/18 patients du groupe P présentaient des scores de sédation τ;1, comparé à 0/28 patients dans le groupe G (P=0,05).Conclusion: La gabapentine 1200 mg administrée de façon préventive ne réduit pas l’incidence ou la sévérité de la douleur à l’épaule post-thoracotomie chez les patients recevant une analgésie péridurale thoracique.

Pilot study of pulmonary arterial branch sealing using energy devices in an ex vivo model

OBJECTIVE Vascular endostaplers are bulky and can be dangerous when dividing small pulmonary arterial (PA) branch vessels during video-assisted thoracoscopic lobectomy. We aimed to evaluate and compare the immediate efficacy of modern energy sealing devices in an ex vivo PA sealing model. METHODS Patients undergoing anatomical lung resection or lung transplantation were recruited for a prospective cohort pilot study. Four devices were evaluated: Harmonic Ace (Ethicon, Cincinnati, Ohio), Thunderbeat (Olympus, Tokyo, Japan), LigaSure (Covidien, Boulder, Colo), and Enseal (Ethicon; Cincinnati, Ohio). After anatomical lung resection, the PA branches were dissected in vitro. Sealing was then performed with 1 of the sealing devices, the vessel was slowly pressurized, and the bursting pressure was recorded. RESULTS Forty-nine PA branches were sealed in 14 patients. The mean PA branch diameter was 7.4 mm (1.8-14.5 mm). Ten patients had normal PA pressure and 3 had PA hypertension. The mean bursting pressure in each was as follows: Harmonic Ace group, 415.5 mm Hg (137.1-1388.4 mm Hg), Thunderbeat group, 875 mm Hg (237.1-2871.3 mm Hg); LigaSure group, 214.7 mm Hg (0-579.6 mm Hg); Enseal group, 133.7 mm Hg (0-315.38 mm Hg). There were 2 complete sealing failures: LigaSure (diameter 6.78 mm) and Enseal (diameter 8.3 mm). CONCLUSIONS In this pilot study to examine energy sealing of PA branches in a simulated ex vivo model, vascular sealing using energy was effective and was able to sustain high intraluminal bursting pressures. Further research is needed to determine the in vivo and long-term safety of PA branch energy sealing.

Oculopharyngeal muscular dystrophy: What's new?

The authors place autosomal dominant oculopharyngeal muscular dystrophy in a historical perspective, look at the genealogy involved, and review the genetic studies. In addition to summarizing what happens at the histopathological level, they examine the clinical characteristics of this late-onset dystrophy. Based on this knowledge, they try to present their rationale for the surgical treatment of the eyelid ptosis, taking into account that this disease is progressive and that treatment should be planned for the lifetime of the patient. Three representative cases are illustrated.

Impact of pregabalin on the occurrence of postthoracotomy pain syndrome: a randomized trial.

Background Postthoracotomy pain syndrome (PTPS) is a frequent cause of chronic postoperative pain. Pregabalin might reduce the incidence of chronic postoperative pain. The goal of this study was to evaluate the impact of perioperative pregabalin on the occurrence of PTPS, defined as any surgical site pain 3 months after surgery. Methods We conducted a randomized, placebo-controlled, double-blind trial in patients undergoing elective thoracotomy. Patients received either pregabalin 150 mg orally twice a day initiated 1 hour before thoracotomy and continued until 4 days after thoracotomy (10 doses total) or a placebo using the same protocol. All patients received preincision thoracic epidural analgesia. Postthoracotomy pain syndrome was evaluated using the Brief Pain Inventory questionnaire through a telephone interview. Secondary outcomes included evaluation of neuropathic characteristics through the Leeds Assessment of Neuropathic Symptoms and Signs questionnaire, analgesic use 3 months after surgery, and evaluation of acute postoperative pain and opioid consumption. Results One hundred fourteen patients were randomized, and 99 patients completed the study (placebo, n = 49; pregabalin, n = 50). Postthoracotomy pain syndrome occurred in 49 (49.5%) of 99 patients and more frequently in the pregabalin group (31/50 [62%] vs 18/49 [37%] in the placebo group, P = 0.01). However, among patients with PTPS, those in the pregabalin group required significantly less analgesics, reported less moderate to severe average pain, and presented significantly less neuropathic characteristics than patients in the placebo group 3 months after surgery. Conclusions Pregabalin did not reduce the incidence of PTPS in this study. Future research on PTPS should focus on the impact of regional analgesia on central sensitization.

Influence of abdomen on respiratory mechanics in supine rabbits

Previous studies showed that abdominal evisceration has no effect on respiratory system compliance. We hypothesized that this could be related to lung distortion in eviscerated animals. Methods were developed for continuous recording of pleural pressure (Ppl) at various sites over the costal (co) and diaphragmatic lung surface (di) in acutely and chronically instrumented rabbits. We compared deltaPpl,co and deltaPpl,di recorded at mid-lung height during inflations in anesthetized, paralyzed supine rabbits before and after evisceration. Cranial and caudal deltaPpl.co were the same under all conditions. In intact animals, deltaPpl.co and deltaPpl,di were equal at all inflation volumes, whilst in eviscerated animals, deltaPpl,di were smaller than deltaPpl,co, the difference increasing with lung inflation. At any given volume, rib cage circumference (Crc) was smaller after evisceration, but the Crc deltaPpl,co relationship remained unchanged. These results are indicative of non-uniform lung expansion after evisceration and are consistent with model predictions based on cylindrical deformation and lung stress-strain relationship. This deformation should mimic the effect of a reduced lung compliance, keeping respiratory system compliance of eviscerated animals nearly normal. Similar deformation should have occurred also in intact rabbits during strong inspiratory efforts and in the erect posture, because lower Ppl,di than Ppl,co values were observed at the same lung height under these conditions.

Pulmonary artery sealing with ultrasonic energy in open lobectomy: A phase I clinical trial

Objective: Pulmonary artery branch sealing in video‐assisted thoracoscopic surgical lobectomy is usually achieved with vascular endostaplers. Iatrogenic pulmonary artery injury may be caused by endostaplers. We evaluated the safety of pulmonary artery sealing with an ultrasonic energy vessel‐sealing device in a phase I clinical trial evaluating in vivo safety of the device during open lobectomy. Methods: Patients scheduled to undergo elective open (thoracotomy) pulmonary lobectomy were prospectively enrolled. Target sample size was 10 patients. Pulmonary artery diameter was measured intraoperatively. All branches ≤7 mm were divided with an ultrasonic energy vessel‐sealing device. The remainder of the lobectomy was performed in a standard fashion. Intraoperative and postoperative bleeding were strictly recorded. Results: Eighteen patients were prospectively enrolled. Eight patients were not amenable to pulmonary artery sealing with the device. In the 10 patients included in the analysis, a total of 14 pulmonary arteries were sealed with the ultrasonic device. The mean vessel diameter was 5 mm (range, 2–7 mm). One patient underwent reoperation for bronchial artery bleeding (vessel not sealed with device). There was no intra‐ or postoperative bleeding related to ultrasonic pulmonary artery sealing. There was no postoperative mortality. Conclusions: Pulmonary artery sealing for vessels with diameter ≤7 mm was safely achieved with an ultrasonic energy vessel‐sealing device in open lobectomy. The use of ultrasonic energy vessel‐sealing devices in video‐assisted thoracoscopic surgical lobectomy may have the advantage of making small, short, pulmonary artery branch sealing safer than with vascular endostaplers. Further studies are necessary before widespread application in lobectomy, including video‐assisted thoracoscopic surgical lobectomy.