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C.S. Pramesh



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    O09 - General Thoracic Surgery (ID 100)

    • Event: WCLC 2013
    • Type: Oral Abstract Session
    • Track: Surgery
    • Presentations: 1
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      O09.07 - Phase II Double-blind Randomized trial comparing Posterolateral Thoracotomy versus Nerve Sparing Thoracotomy for lung surgery (PoTNeST) - Impact of preservation of the neurovascular bundle during thoracotomy on post-operative pain (ID 2587)

      17:20 - 17:30  |  Author(s): C.S. Pramesh

      • Abstract
      • Presentation
      • Slides

      Background
      Posterolateral thoracotomy has been extensively used for non-cardiac thoracic surgery. Although this procedure provides excellent access for cancer surgery, it is responsible for considerable postoperative pain and contributes to postoperative pulmonary insufficiency. Post-thoracotomy pain has been reported to occur in 10 to 70% of patients. Intercostal nerve injury has been implicated as a major factor in the etiology of post-thoracotomy pain. We performed a study to compare post-thoracotomy pain in patients undergoing posterolateral thoracotomy with and without the preservation of the intercostal neurovascular bundle.

      Methods
      This randomized double-blind phase II trial was carried out in a tertiary-referral cancer centre. We included adult patients undergoing posterolateral thoracotomy for pulmonary resection. Patients were randomized into two groups – standard posterolateral thoracotomy (PoT) where no attempt was made to preserve the intercostals neurovascular bundle or modified nerve-sparing thoracotomy (NeST) which involved preservation of the intercostal neurovascular bundle while opening the intercostal space and closure by drilling holes in the lower rib, thereby avoiding pericostal sutures. All surgeries were performed under general anaesthesia with fentanyl, morphine, diclofenac and paracetamol for intra-operative analgesia. Post-operatively, all patients received round-the-clock paracetamol and diclofenac with an intravenous morphine patient-controlled analgesia pump for additional analgesia. Worst and average pain scores (on a Numerical Rating Scale) and morphine requirements on the first three post-operative days were assessed. Patients and assessors were blinded to study group. Chronic pain was assessed 6 months after surgery using a standard questionnaire. The primary outcome was the mean worst pain score over the first three post-operative days. Secondary outcomes were mean average pain score over the first three post-operative days, morphine consumption and incidence of post-thoracotomy pain at 6 months.

      Results
      We recruited 90 patients between May 2010 and July 2012. Groups were comparable in terms of age, gender, weight and type of surgery. There was no significant difference between the PoT and the NeST group in mean worst pain scores over the first three post-operative days (3.83 versus 3.71, difference 0.12, 99% CI -0.7 to 0.9). Mean average pain scores were also similar between the groups (1.85versus 1.77, difference 0.08, 99% CI -0.4 to 0.6) as was the mean morphine consumption in milligram per kilogram body weight (1.40 versus 1.45, difference of -0.05, 99% CI -0.4 to 0.3). Chronic pain was present in 18 of 39 assessable patients (46.1%) in the PoT group and 17 of 41 assessable patients (41.2%) in the NeST group (difference 4.7%, 99% CI -22.8% to 30.7%).

      Conclusion
      Preservation of the neurovascular bundle during thoracotomy using a modified nerve-sparing approach has no impact on acute or chronic post-thoracotomy pain or analgesic requirements as compared to a standard posterolateral approach.

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    P2.07 - Poster Session 2 - Surgery (ID 190)

    • Event: WCLC 2013
    • Type: Poster Session
    • Track: Surgery
    • Presentations: 1
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      P2.07-026 - Does surgeon grade influence early postoperative outcomes in major resection for lung tumors? (ID 2386)

      09:30 - 09:30  |  Author(s): C.S. Pramesh

      • Abstract

      Background
      Postoperative complications are common after major lung resections for cancer. Although there have been important advances in operative technique and perioperative care, lung resection for cancer is still a major surgery with higher incidence of complications in centres with a low case volume. We undertook a retrospective analysis of a prospectively maintained surgical database to ascertain whether the grade of the operating surgeon influenced the occurrence of postoperative complications and mortality in a tertiary level teaching cancer centre.

      Methods
      Data from a prospectively maintained database (Aug 2004 to May 2013) was analysed and the following parameters were retrieved: age, sex, type of surgery, grade of surgeon (Consultant vs trainee), postoperative major complications including pulmonary complications, air leak, bronchopleural fistula and mortality. ICU and hospital stay were also compared between surgeries performed by consultants and trainees. Categorical variables were analysed by the Chi square or Fischer’s exact test and numerical variables using the unpaired Student t test. P values less than 0.05 were considered statistically significant.

      Results
      A total of 654 patients (494 male, 160 female; mean age 54.4, range 14 to 83 years) underwent lung resection for primary lung tumors in the study period. The overall major morbidity and postoperative mortality was 10.6% and 1.7% respectively. Consultant thoracic surgeons performed 532 surgeries while trainees performed 122 procedures. Major morbidity was 11.2% and 8.2% (p=0.336) and postoperative mortality was 1.9% and 0.8% (p=0.628) when lung resection was performed by consultants and trainees respectively. The incidence of pulmonary complications (10.2% vs 9.9%, p=0.916) and bronchopleural fistula (2.2% vs 1.8%, p=0.749), median ICU (both 0 days) and hospital stay (both 5 days) were also similar in the two groups.

      Conclusion
      Early postoperative outcomes after major lung resection for primary lung tumors are independent of the level of training of the operating surgeon. These results are qualified by the fact that operations performed by trainees were closely supervised and assisted by experienced consultant thoracic surgeons in a teaching tertiary level cancer centre.