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Open esophagectomy involves laparotomy and thoracotomy. Laparoscopic abdominal surgery may be useful for reducing complications, but does it control the cancer? A trial suggests that morbidity is lower and cancer outcomes are at least as good with the hybrid procedure as with the open procedure.

Video-assisted thoracoscopic surgery (VATS) is used increasingly as an alternative to thoracotomy for lobectomy in the treatment of early-stage non-small-cell lung cancer, but remains controversial and worldwide adoption rates are low. Non-randomised studies have suggested that VATS reduces postoperative morbidity, but there is little high-quality evidence to show its superiority over open surgery. We aimed to investigate postoperative pain and quality of life in a randomised trial of patients with early-stage non-small-cell lung cancer undergoing VATS versus open surgery. We did a randomised controlled patient and observer blinded trial at a public university-based cardiothoracic surgery department in Denmark. We enrolled patients who were scheduled for lobectomy for stage I non-small-cell lung cancer. By use of a web-based randomisation system, we assigned patients (1:1) to lobectomy via four-port VATS or anterolateral thoracotomy. After surgery, we applied identical surgical dressings to ensure masking of patients and staff. Postoperative pain was measured with a numeric rating scale (NRS) six times per day during hospital stay and once at 2, 4, 8, 12, 26, and 52 weeks, and self-reported quality of life was assessed with the EuroQol 5 Dimensions (EQ5D) and the European Organisation for Research and Treatment of Cancer (EORTC) 30 item Quality of Life Questionnaire (QLQ-C30) during hospital stay and 2, 4, 8, 12, 26, and 52 weeks after discharge. The primary outcomes were the proportion of patients with clinically relevant moderate-to-severe pain (NRS ≥3) and mean quality of life scores. These outcomes were assessed longitudinally by logistic regression across all timepoints. Data for the primary analysis were analysed by modified intention to treat (ie, all randomised patients with pathologically confirmed non-small-cell lung cancer). This trial is registered with ClinicalTrials.gov, number NCT01278888. Between Oct 1, 2008, and Aug 20, 2014, we screened 772 patients, of whom 361 were eligible for inclusion and 206 were enrolled. We randomly assigned 103 patients to VATS and 103 to anterolateral thoracotomy. 102 patients in the VATS group and 99 in the thoracotomy group were included in the final analysis. The proportion of patients with clinically relevant pain (NRS ≥3) was significantly lower during the first 24 h after VATS than after anterolateral thoracotomy (VATS 38%, 95% CI 0·28–0·48 vs thoracotomy 63%, 95% CI 0·52–0·72, p=0·0012). During 52 weeks of follow-up, episodes of moderate-to-severe pain were significantly less frequent after VATS than after anterolateral thoracotomy (p<0·0001) and self-reported quality of life according to EQ5D was significantly better after VATS (p=0·014). By contrast, for the whole study period, quality of life according to QLQ-C30 was not significantly different between groups (p=0·13). Postoperative surgical complications (grade 3–4 adverse events) were similar between the two groups, consisting of prolonged air leakage over 4 days (14 patients in the VATS group vs nine patients in the thoracotomy group), re-operation for bleeding (two vs none), twisted middle lobe (one vs three) or prolonged air leakage over 7 days (five vs six), arrhythmia (one vs one), or neurological events (one vs two). Nine (4%) patients died during the follow-up period (three in the VATS group and six in the thoracotomy group). VATS is associated with less postoperative pain and better quality of life than is anterolateral thoracotomy for the first year after surgery, suggesting that VATS should be the preferred surgical approach for lobectomy in stage I non-small-cell lung cancer. Simon Fougner Hartmanns Familiefond, Guldsmed AL & D Rasmussens Mindefond, Karen S Jensens legat, The University of Southern Denmark, The Research Council at Odense University Hospital, and Department of Cardiothoracic Surgery, Odense University Hospital.

Surgical intervention is essential for managing organizing thoracic empyema, but the efficacy of Video-Assisted Thoracic Surgery (VATS) in this disease stage remains debated. This study aims to compare the surgical outcomes of VATS versus open thoracotomy (OT) in the management of organizing thoracic empyema. This retrospective cohort study included 393 patients who underwent surgery for organizing thoracic empyema at Maharaj Nakorn Chiang Mai Hospital between January 1, 2012, and December 31, 2022, and were divided into VATS and OT groups. The primary outcomes were lung full expansion before discharge and at the 2-week follow-up. Secondary outcomes included intraoperative blood loss, duration of intensive care unit (ICU) stay, and postoperative pain scores. Data analysis was performed using multivariable regression analysis and propensity score matching. In the propensity-matched cohort (212 patients), patient characteristics were balanced between the two groups. VATS was associated with a higher likelihood of full lung expansion at discharge (risk ratio: 1.21; 95% CI: 1.01 to 1.45compared to OT. There were no significant differences in postoperative pain scores, or full lung expansion at 2 weeks after discharge between the two groups. However, the VATS group showed a trend toward less intraoperative blood loss (mean difference: -34.20; 95%CI: -162.89 to 94.49). VATS offers advantages over OT in organizing thoracic empyema surgery, particularly in terms of improved lung expansion at discharge. Further studies with larger sample sizes are warranted to support these findings.

Background Right lateral thoracotomy is increasingly used because of its cosmetic benefits, shorter hospital stays, rapid return to full activity, and ease of reoperation in pediatric patients with uncomplicated congenital heart disease. Currently, one-lung ventilation (OLV) is used in these children to facilitate surgical exposure. We aimed to assess the effect of OLV on postoperative outcomes. Methods Children aged 6 months to 6 years undergoing right lateral thoracotomy cardiac surgery with cardiopulmonary bypass (CPB) were randomized into an OLV group or a control group. For the OLV group, the tidal volume was 5 ml/kg with 6 cmH₂O positive end-expiratory pressure from the incision until the end of CPB, whereas patients in the control group received two-lung ventilation, except during vena cava occlusion. Lung ultrasonography was performed twice in the supine position for each patient: first, 3 min after intubation before surgery (T 1 ), and second, 3 min after lung recruitment maneuvers at the end of surgery (T 2 ). The primary outcome was the incidence of postoperative pulmonary complications within 72 h of surgery and significant atelectasis (defined by a consolidation score of ≥ 2 in any region) at T 2 . Results Overall, 54/96 (56.3%) children developed postoperative pulmonary complications after lateral thoracotomy cardiac surgery with CPB. The incidence of postoperative pulmonary complications was 52.1% (25/48) and 60.4% (29/48) in the OLV and control groups, respectively (odds ratio: 0.712; 95% confidence interval: 0.317–1.600; p  = .411). At the end of surgery, the incidence of significant atelectasis was 37.5% in the OLV group compared to 64.6% in the control group (odds ratio: 0.329; 95% confidence interval: 0.143–0.756; p  = .008). The consolidation score of the left lung (dependent lung) in the OLV group was significantly lower than that in the control group ( p  = .007); there was no significant difference in the right lung's postoperative consolidation score between the two groups ( p  = .051). Conclusions There was no significant difference in the incidence of postoperative pulmonary complications within 72 h of surgery between the two groups. However, children who underwent right lateral thoracotomy cardiac surgery with CPB in the OLV group showed a low incidence of atelectasis at the end of surgery. Trial registration ChiCTR, ChiCTR2100048720. Registered on July 13, 2021, www.chictr.org.cn .

The primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects. Single-center, prospective, observational study. Recruitment between December 2017 and August 2018. Perioperative care at university-affiliated tertiary care centre. 202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded. Thoracotomy (n = 106) and sternotomy (n = 96). Pain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire. Incidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects. Our study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months. •Cardiac surgery through thoracotomy has been postulated to decrease pain and accelerate recovery compared to sternotomy.•More than half of patients experience moderate to severe pain during the first 24h independently of the surgical approach.•The incidence of acute and persistent postoperative pain decreases over time.•There is no association between surgical approach and incidence or intensity of acute and persistent pain.

OBJECTIVES Completion lobectomy (CL) after anatomical segmentectomy in the same lobe can be complicated by severe adhesions around the hilar structures and may lead to fatal bleeding and lung injury. Therefore, we aimed to investigate the perioperative outcomes of CL after anatomical segmentectomy. METHODS Among 461 patients who underwent anatomical segmentectomy (thoracotomy, 62 patients; thoracoscopic surgery, 399 patients) between January 2005 and December 2019, data of patients who underwent CL after segmentectomy were extracted and analysed in this study. RESULTS Eight patients underwent CL after segmentectomy. CL was performed via video-assisted thoracic surgery in 3 patients and thoracotomy in 5 patients. In each case, there were moderate to severe adhesions. Four patients required simultaneous resection of the pulmonary parenchyma and pulmonary artery. Thoracotomy was not required after thoracoscopic surgery in any patient. Two patients experienced complications (air leakage and arrhythmia). The median duration of hospitalization after CL was 6 (range, 5–7) days. No postoperative mortality or recurrence of lung cancer was observed. All the patients with lung cancer were alive and recurrence-free at the time of publication. CONCLUSIONS Although individual adhesions render surgery difficult, CL after anatomical segmentectomy shows acceptable perioperative outcomes. However, CL by video-assisted thoracoscopic surgery may be considered on a case-by-case basis depending on the initial surgery.

Background Lung cancer surgery has evolved significantly, with minimally invasive video-assisted thoracic surgery (VATS) procedures being compared with traditional open thoracotomies. The incidence of postoperative wound infections is a significant factor influencing the choice of surgical technique. This systematic review and meta-analysis aim to evaluate the impact of thoracoscopic versus open thoracotomy procedures on postoperative wound infections in lung cancer patients. Methods Following PRISMA guidelines, a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library was conducted on September 19, 2023, without time or language restrictions. Peer-reviewed randomized controlled trials, cohort studies, and case-control studies reporting on postoperative wound infections were included. Studies not differentiating between surgical techniques or focusing on irrelevant populations were excluded. Data extraction and quality assessment were independently carried out by two reviewers, using a fixed-effect model for meta-analysis due to the absence of significant heterogeneity (I 2  = 0.0%, P  = 0.766). Results A total of six articles were included. The quality assessment indicated a low risk of bias in most domains. The pooled results showed that open thoracotomy procedures had a twofold increased risk of postoperative wound infections (OR = 2.00, 95% CI: 1.04–3.85) compared to VATS procedures. Publication bias assessment using funnel plots and Egger’s test revealed no significant biases ( P  > 0.05). Conclusions The findings suggest that VATS is associated with a lower risk of postoperative wound infections compared to open thoracotomy, which has implications for surgical decision-making in lung cancer treatment. Clinical trial number Not applicable.

Background Pulmonary hydatid cyst disease is a common zoonotic infection, especially in agricultural and livestock communities. Thoracotomy is an important surgical procedure in the treatment of pulmonary hydatid cysts in children. However, the development of a spinal deformity is one of the long-term musculoskeletal complications of this procedure. The aim of this study was to evaluate the incidence, risk factors and clinical outcomes of spinal deformity in pediatric patients after thoracotomy. Methods Between 2008 and 2022, 116 pediatric patients who underwent thoracotomy for pulmonary hydatid disease and met the study criteria were retrospectively reviewed. Age, sex, side of surgery, pre- and postoperative spinal radiographs, presence of spinal deformity and Cobb angles were measured. Results Spinal deformities developed in 57.8% of 116 patients after thoracotomy. The risk of spinal deformity increases with decreasing age at surgery. The side of the thoracotomy can influence the direction of the apex of the spinal deformity. However, sex had no significant effect on the development of spinal deformity. Conclusions Children with pulmonary hydatid cyst disease are at high risk of developing spinal deformity after thoracotomy, and this risk is greater in younger patients. This study emphasises the importance of multidisciplinary approaches in the prevention and management of spinal deformity.

IntroductionBoth thoracic epidural analgesia and thoracic paravertebral analgesia are effective techniques to control pain and minimize the stress response following thoracic surgery. We hypothesized that continuous neuraxial techniques may be associated with a decrease in the incidence of postoperative mortality after thoracotomy. Additionally, we aimed to identify subgroup populations that may benefit more from neuraxial anesthesia.Method1620 patients who underwent open thoracotomy were included in this retrospective study from the German Thoracic Registry database at four university hospitals. All-cause inpatient mortality was determined for patients who had and did not have neuraxial anesthesia. Logistic regression was used to adjust for and explore various covariates.ResultsContinuous neuraxial analgesia was associated with a lower overall mortality in the postoperative period (2.9%, 23/796 vs 5.3%, 44/824, p=0.02) only after the univariate analysis but not the multivariable analysis (OR 0.49, 95 % CI 0.237 to 1.12, p=0.15). In patients with epidural or paravertebral catheters, mortality was significantly lower in the following subgroups: age >75 (5/113 vs 18/77, OR 0.1, 95% CI 0.02 to 0.67, p=0.02), American Society of Anesthesiologists Performance Score >III (11//97 vs 33/155, OR 0.32, 95% CI 0.11 to 0.89, p=0.03), chronic kidney disease (5/83 vs 16/77, OR 0.16, 95% CI 0.03 to 0.82, p=0.03), and postoperative sepsis (9/21 vs 17/25, OR 0.13, 95% CI 0.07 to 0.44, p<0.01).ConclusionsNeuraxial analgesic techniques are associated with reductions in postoperative mortality after open thoracic surgery in selected patients.

Pain following thoracotomy is of moderate to severe nature. Management of thoracotomy pain is a challenging task. Post thoracotomy pain has acute effects in the post operative period by affecting respiratory mechanics, which increases the morbidity. Poorly controlled thoracotomy pain in the acute phase may also lead to the development of a chronic pain syndrome. A young male patient underwent esophagectomy and esophago-gastric anastomosis for corrosive stricture of the esophagus. Epidural analgesia is standard of care for patients undergoing thoracotomy. Due to hypotension and fluid losses following surgery, he was maintained on intravenous sedatoanalgesia during postoperative mechanical ventilation. The thoracic epidural catheter which was placed pre-operatively, had developed blockage during the hospital stay. However, during weaning from ventilation and sedation, he indicated severe pain in the thoracotomy incision. The pain was severe enough to impair tidal breathing. We wanted to evaluate the efficacy of the serratus anterior plane block in the management of thoracotomy pain. The usefulness of this block has been discussed in the management of pain of rib fractures and breast surgeries. Despite the hypothesis of its usefulness in causing anaesthesia of the hemithorax, there are no available reports of clinical use for pain relief following thoracotomy. We performed the serratus anterior place block under ultrasound guidance and placed a catheter for continuous infusion of local anaesthetic and opioid. The patient had significant pain relief following a single bolus of the drug. The infusion was started thereafter, which provided excellent analgesia and facilitated an uneventful recovery. Here, we describe the successful management of thoracotomy pain using the serratus anterior plane block. Key words: Serratus anterior plane block, post-thoracotomy pain