Gonzalo Vidal

Comparative analysis of analgesic quality in the postoperative of thoracotomy: paravertebral block with bupivacaine 0.5% vs ropivacaine 0.2%.

OBJECTIVES Paravertebral block is an effective alternative to epidural analgesia in the management of post-thoracotomy pain, however, there are no established guidelines regarding what is the most suitable strategy when varying drugs and dosages between different groups. Our objective was to evaluate the effectiveness of paravertebral block comparing the most frequently employed drugs in this procedure (bupivacaine vs ropivacaine). METHODS Prospective randomized study of 70 patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). At the end of surgery a catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group (AT or PT) patients were randomized to receive a bolus of 15 ml of bupivacaine 0.5% or 20 ml of ropivacaine 0.2% before closing the thoracotomy. They postoperatively received 10 ml of bupivacaine or 15 ml of ropivacaine every 6h combined with methamizol (every 6h). Subcutaneous meperidine was employed as rescue drug. The level of pain was measured with the visual analogic scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as rescue drug and secondary effects was also recorded. RESULTS We did not register secondary effects in relation to the paravertebral catheter (paravertebral or cutaneous bleeding or hematoma, respiratory depression (respiratory rate <8 breaths per minute), cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting and pruritus). Eleven patients (16%) needed meperidine as rescue drug (six with ropivacaine and five with bupivacaine). Mean VAS values were the following: all the cases (n=70): 5.2+/-2.1, AT (n=38): 4.5+/-2.1, PT (n=32): 5.9+/-1.7, bupivacaine (n=35): 4.9+/-2.1, ropivacaine (n=35): 5.4+/-1.9, AT with bupivacaine (n=19): 4.2+/-2.2, AT with ropivacaine (n=19): 4.9+/-2.0, PT with bupivacaine (n=16): 5.7+/-1.6, PT with ropivacaine (n=16): 6.0+/-1.7. CONCLUSIONS Post-thoracotomy analgesia combining paravertebral catheter and a nonsteroidal anti-inflammatory drug is a safe and effective practice, VAS values are acceptable (only 16% of patients required meperidine as rescue). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.5 vs 5.9, p<0.01). Bupivacaine got slightly better VAS values than ropivacaine (4.9 vs 5.4 p<0.05). Higher doses and volumes of local anesthetic could be used to obtain better VAS values.

Effectiveness of sympathetic block by clipping in the treatment of hyperhidrosis and facial blushing.

Main cause of dissatisfaction after videothoracoscopic (VATS) sympathectomy in the treatment of hyperhidrosis (HH) and facial blushing (FB) is compensatory sweating (CS). Sympathetic nerve (SN) clipping permits to revert the block effect by removing the clips in case of an intolerable CS. We present our experience with this technique. Sixty-one patients diagnosed for HH and/or FB were operated on VATS SN clipping. Clipping levels varied in function for the sort of disease: FB: T2, palmar HH: T3, axillary HH: T4, palmar-axillary HH: T3-4. Results were evaluated 1 week, 3 months and 12 months after surgery. Fifty-eight of the 61 patients showed improvement of their symptoms (95%). There were minor complications in three patients (5.5%). CS was seen in 38/61 (62.2%), being labelled as mild in 33/61 (54%) and severe in 5/61 patients (8.2%), no patient qualified it as intolerable and it was not necessary to remove the clips for CS in any case. SN clipping by VATS is a safe and effective procedure for the management of FB and palmar/axillary HH. Levels of CS are similar or lesser than with the standard sympathicotomy and, if necessary, this technique allows to revert the sympathetic block removing the clips.

A prospective study of analgesic quality after a thoracotomy: paravertebral block with ropivacaine before and after rib spreading §

OBJECTIVE Paravertebral block (PVB) is an effective alternative to epidural analgesia in the management of post-thoracotomy pain. Rib spreading (RS) is an important noxious stimulus considered a major cause of post-thoracotomy pain. Our hypothesis was that a bolus of ropivacaine 0.2% through a paravertebral catheter (PVC) inserted before RS could decrease pain during the first 72 postoperative hours. METHODS The methodology employed was to perform a prospective randomised study of 60 consecutive patients submitted to thoracotomy. Patients were divided in two independent groups (anterior thoracotomy (AT) and posterolateral thoracotomy (PT)). A catheter was inserted under direct vision in the thoracic paravertebral space at the level of incision. In each group, patients were randomised to receive a bolus of 20 ml of ropivacaine 0.2% before rib spreading (pre-RS) or after (post-RS), just before closing the thoracotomy. They postoperatively received 15 ml of ropivacaine 0.2% every 6 h combined with methamizol (every 6h). Subcutaneous meperidine was employed as a rescue drug. The level of pain was measured with the visual analogue scale (VAS) at 1, 6, 24, 48 and 72 h after surgery. The need of meperidine as a rescue drug and secondary effects were also recorded. RESULTS We did not register secondary effects in relation to the PVC (paravertebral or cutaneous bleeding or haematoma, respiratory depression, cardiotoxicity, confusion, sedation, urinary retention, nausea, vomiting or pruritus). Seven patients (11.6%) needed meperidine as rescue drug (four pre-RS and three post-RS). The mean VAS values were the following: all cases (n=60): 4.7+/-2.0; AT (n=32): 4.0+/-2.1; PT (n=28): 5.6+/-1.8; pre-RS (n=30): 4.8+/-1.9; post-RS (n=30): 4.6+/-2.0; AT-pre-RS (n=16): 4.1+/-2.0; AT-post-RS (n=16): 3.9+/-2.1; PT-pre-RS (n=14): 5.6+/-1.6; PT-post-RS (n=14): 5.4+/-1.7. CONCLUSIONS Post-thoracotomy analgesia combining PVC and a non-steroidal anti-inflammatory drug is a safe and effective practice. VAS values are acceptable (only 11.6% of patients required meperidine). It prevents the risk of side effects related to epidural analgesia. Patients submitted to AT experienced less pain than those with PT (4.0 vs 5.6; p<0.01). PVB with ropivacaine before RS got similar VAS values than the block after RS (4.8 vs 4.6; p>0.05). The moment of the insertion of the PVC does not seem to affect postoperative pain levels.

The Yield of Mediastinoscopy with Respect to Lymph Node Size, Cell Type, and the Location of the Primary Tumor

Background: The aim of this study was to investigate the yield of cervical mediastinoscopy (CM) for pathologically diagnosed non-small cell lung cancer (NSCLC), with respect to lymph node size on computed tomography (CT), cell type, and the location of the primary tumor. Methods: We reviewed 142 patients who underwent standard cervical mediastinoscopy from April of 1994 to June of 2003 for pathologically diagnosed NSCLC. The staging yield was determined by the percentage of “positive” CM (metastatic paratracheal or subcarinal nodes). Mediastinoscopy was performed when the lymph node diameter was >1 cm and, since 2001, whenever paratracheal or subcarinal lymph nodes were clearly seen on CT, regardless of size. Group A includes patients with lymph nodes on CT of ≥1 cm. Group B includes patients with lymph nodes of <1 cm. The &khgr;2 test was used for statistical analysis. Results: We performed CM on 142 patients. There were 127 men (89.4%) and 15 women (10.6%). The mean age of the patients was 64.7 years (range, 38–83). The global yield was 28.2% (CM positive in 40 of 142 cases). The specific yield by groups was as follows, with respect to lymph node size: group A (lymph nodes >1 cm), 37.9%, and group B (lymph nodes <1 cm), 8.5% (p < 0.01). With respect to cell type, 16.3% were squamous tumors, 42.9% were adenocarcinomas (p < 0.01), 45.5% were large-cell carcinomas, and 44.4% were other types. With respect to the location of the primary tumor and T stage, there were no statistically significant differences (p = 0.09). When only patients with squamous tumors with no enlarged lymph nodes were considered, staging yield was 3.3% (one of 30), and 19.6% (20 of 102) of patients with a negative CM had positive mediastinal lymph nodes at the time of the resection. The yield was 9.8% (10 of 102 patients) in the territory accessible by CM at the time of the resection (true false negative), and 9.8% (10 of 102 patients) in the territory not accessible by CM. Conclusion: Lymph node size and cell type of primary tumors should be taken into account when selecting patients for staging with standard MC in NSCLC. In patients with squamous-type tumors with lymph nodes <1 cm on CT, CM could be avoided because its low yield.

Resultados de la simpaticotomía videotoracoscópica en el tratamiento del rubor y la hiperhidrosis facial en 41 pacientes

Resumen Objetivo Valorar los resultados y complicaciones de la simpaticotomia toracica videotoracoscopica (VATS) en el tratamiento de los pacientes diagnosticados de rubor facial incontrolable y/o hiperhidrosis facial. Pacientes y metodo Entre mayo de 2000 y agosto de 2006, llevamos a cabo 82 simpaticotomias toracicas por VATS en 41 pacientes diagnosticados de rubor facial incontrolable y/o hiperhidrosis facial. Dos de ellos habian sido intervenidos anteriormente sin resultados satisfactorios. La tecnica empleada fue la simpaticotomia bilateral, variando los niveles en funcion de la presencia de hiperhidrosis palmar y/o axilar asociada y de las limitaciones anatomicas. Los resultados fueron evaluados a la semana y a los 3-6 meses en los 41 pacientes y al ano de la intervencion en 34 pacientes. Resultados Habia 22 varones y 19 mujeres, con una media de edad de 33,7 (intervalo, 18-56) anos. En 17 (41,5%) pacientes el sintoma principal era la hiperhidrosis facial y en 24 (58,5%), el rubor facial incontrolable. Todos los pacientes fueron dados de alta antes de las 24 h de la intervencion, 14 de ellos en un programa de cirugia sin ingreso. Se obtuvo mejoria de la hiperhidrosis facial en todos los casos 17/17 (100%). En el grupo de rubor la tecnica fue eficaz en 20/24 (83,3%) casos. Se obtuvo resultados satisfactorios con la segunda intervencion. Se constato sudoracion compensadora en 16/41 (39%) pacientes, que fue grave en 6 (14.6%). Conclusiones La simpaticotomia toracica por VATS es un procedimiento seguro y efectivo para el manejo de la hiperhidrosis facial y el rubor incontrolable. La sudoracion compensadora permanece como el principal efecto secundario.

Ventana pericárdica por videotoracoscopia en el tratamiento de derrame y/o taponamiento pericárdico

Resumen Introduccion Las causas mas frecuentes de derrame pericardico (DP) y/o taponamiento pericardico (TP) son los tumores malignos. Los mas habituales son el carcinoma broncogenico y el de mama. El tratamiento es el drenaje y/o ventana pericardica (VP) habitualmente realizados por via subxifoidea. En este estudio empleamos el abordaje por videotoracoscopia (VTC), un procedimiento poco referido en la literature medica. Objetivo Evaluar la eficacia del tratamiento del DP y/o TP mediante la realizacion de una VP por VTC. Pacientes y metodos Estudio retrospectivo de 12 pacientes diagnosticados de DP y a los que se practico una VP mediante VTC durante un periodo de 10 anos (entre febrero de 1994 y octubre de 2004). El procedimiento quirurgico empleado fue la VTC, con anestesia general, intubacion selectiva y decubito lateral. Se efectuo de manera sistematica una VP anterior al nervio frenico y el estudio del liquido pericardico y pleural. Se anadio pleurodesis con talco si habia derrame pleural neoplasico –filiado previamente mediante toracocentesis y citologia del liquido pleural–. Se dejo un drenaje pleural (24 F) que se retiro cuando el debito fue menos de 100 ml al dia. Resultados Se intervino a 12 pacientes, 4 varones y 8 mujeres, con una media (intervalo) de edad de 58,6 (32-78) anos. La mortalidad quirurgica fue nula. Hubo 8 casos de TP. Las causas de DP fueron: cancer de mama en 8 casos, carcinoma broncogenico en 3 casos y un caso de origen infeccioso. La duracion media del acto operatorio fue 30 min. Los 12 pacientes presentaron derrame pleural asociado. El abordaje quirurgico fue izquierdo en todos los casos. Se asocio pleurodesis con talco en 8 casos de los 12 que presentaban derrame pleural, en todos ellos la citologia previa del liquido habia sido compatible conderrame pleural paraneoplasico. No hubo mortalidad asociada al procedimiento. El ingreso medio fue 3,8 dias. La supervivencia media fue de 12 meses en el grupo de cancer de mama y 4 meses en el de carcinoma broncogenico. Conclusiones La realizacion de una VP por VTC es una tecnica adecuada para el manejo del DP masivo o el TP. En nuestra experiencia este procedimiento presento una mortalidad nula y una morbilidad minima, y se logro la mejoria sintomatica (en lo que se refiere a correccion del DP y pleural) en todos los casos. Este abordaje permite, ademas, valorar la cavidad pleural, obtener muestras de pleura parietal y, si fuera necesario, realizar pleurodesis con talco.

Bilateral thoracoscopic sympathetic block by clipping

Main cause of dissatisfaction after videothoracoscopic (VATS) sympathectomy in the treatment of hyperhidrosis (HH) and facial blushing (FB) is compensatory sweating (CS). Sympathetic nerve (SN) clipping obtains the same results as sympathectomy in terms of efficacy and safety and levels of CS are similar or lesser than with the standard procedure, with the advantage that if necessary - massive intolerable CS-, this technique theoretically allows to revert the sympathetic block by removing the clips. The surgical procedure is performed through two incisions of 10 mm at the mid axillary and anterior axillary lines (third and fifth intercostal spaces). Through two ports a 30° camera and a diathermy hook are introduced into the pleural cavity. After the identification of the SN, parietal pleura is opened and the chain is isolated. Under video assistance the SN is clipped at the correspondent level with a right-angled endoscopic clip applier. This surgical procedure is illustrated and an overview of the literature is presented.